Kilmer Middle School After-School Program

Registration Consent Form for this School Year

Please read and complete this form prior to attending any Middle School After-School Activities.

FCPS Middle Schools offer a free After-School Program every regular school day (with some exceptions).  This program is staffed by FCPS teachers and staff, NCS staff, and approved contractors and volunteers. After-School Programs include a variety of activities such as homework assistance, school clubs, fine arts, leadership, sports, and other activities. 

The Middle School After-School Program is jointly sponsored by Fairfax County Neighborhood and Community Services and Fairfax County Public Schools and is exempt from licensure as per §22.1-289.030 of the Code of Virginia with no direct oversight by the Virginia Department of Education.  

Specific Information is available at the school and on the school’s website.

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Email *
Consent
I understand that participation in the After-School Program is a privilege and contingent upon student behavior as outlined in the FCPS Student Rights and Responsibilities, as well as School, After-School and FCPS Bus Rules.  Violation of these rules could result in disciplinary action from both the School Day and After-School Programs. 
I understand that participation is completely voluntary, and that some of the planned physical activities may expose my child to some potential injury.  I agree that, to my knowledge, my child is physically and medically able to participate in these activities.  If any injuries do occur to my child, I understand that school and county personnel will respond in the same manner that occurs during regular school hours.  I understand that participation may be denied if my child is consistently picked up late.  I understand that in case of early closing due to inclement weather or emergency conditions, all after-school activities will be canceled.
I understand and hereby grant permission for my child to participate in the Middle School After-School Program for this school year.

Parent/Guardian Name (first and last)

 *
ARMY INVOLVED
Army Youth Programs in Your Neighborhood (AYPYN) provides much needed funding and support for Middle School After-School Programs.  In order to continue this partnership, we must document the number of U.S. Army youth enrolled in our program.

You DO NOT need to be army connected to participate in the After-School Program.
 
Is a parent/guardian actively serving in or a civilian working for the U.S. Army, Army Reserve or National Guard?
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Student Agreement
I (student) understand that participation in the After-School Program is a privilege and contingent upon my behavior as outlined in the FCPS Student Rights and Responsibilities, as well as School, After-School and FCPS Bus Rules.  Violation of these rules could result in disciplinary action from both the School Day and After-School Programs. 

Student Initials *
Student ID Number *
Student Grade Level *
Student's FIRST Name (legal name) *
Student's LAST Name  *
Student's MIDDLE INITIAL (if applicable)
A copy of your responses will be emailed to the address you provided.
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