STRIPES 360 Winter Escape


THIS FORM IS FOR INCLEMENT WEATHER DAYS ONLY!
ONLY KINDERGARTEN - 8TH GRADE STUDENTS MAY PARTICIPATE IN WINTER ESCAPE


Location: McCulloch Elementary. 234 E. Anderson. Please enter through the second set of double glass doors on the west side of the building.

Contact: STRIPES 360 Office 417-735-3778. On the day of program 417-350-3385

Hours of Operation 7:00 am - 6:00 pm


What to Bring: ALL students should bring their lunch with a drink. Morning and afternoon snacks will be provided. Students MUST wear gym shoes and socks. Sandals/flip flops are not appropriate for all activities and should not be worn.

Activities: Students will enjoy STEAM activities (Science, Technology, Engineering, Arts and Mathematics), free play, group games, team builders and other special activities.

Cost: $25 per day per student.
*Note: Payment is due upon arrival at Winter Escape. DFS/DSS Assistance does not cover non school days. Full payment is required for all students.


We check photo identifications daily. No student will be released to leave with someone who refuses to show identification when asked. This is for your child’s safety. Please communicate with anyone on your approved pick-up list to bring identification.

Student 1 Name (Last, First) *
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Student 1 Grade *
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Student 2 Name (Last, First)
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Student 2 Grade
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Student 3 Name (Last, First)
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Student 3 Grade
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Student 4 Name (Last, First)
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Student 4 Grade
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Student Address *
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Primary Parent/Guardian Name *
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Primary Parent/Guardian Contact Phone Number *
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Secondary Parent/Guardian Name
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Secondary Parent/Guardian Phone Number
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Parent Email Address *
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Emergency Contact Name (Other than Parent) *
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Emergency Contact Phone Number *
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Secondary Emergency Contact
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Secondary Emergency Contact Phone Number
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Approved Pick-Up List
Please list anyone who is approved to pick up your student.
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Does your student have a health concern, disabilty, behavioral or developmental need *
ie: allergies, special medical conditions or chronic health problems, etc...
If Yes, please explain
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Photo/Video Release *
The Republic R-III School District STRIPES 360 program may take photos and/or videos of your student while attending the program or on field trips. The photos and/or videos are for general program displays and promotional purposes ie. District Facebook and website. No identifiable information will accompany pictures.
Acknowledgement *
I give my permission for my student to participate in all activities, which are part of the Cub Care program, involving trips away from school grounds on a Republic R-III School District School Bus, and under the supervision of the Cub Care director or designee. Clicking Agree below denotes your signature.
Questions or Comments
Please leave any questions or comments in this section or contact the STRIPES 360 office at 417-735-3778 or aubrey.gideon@republicschools.org
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