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Ivy Preparatory Academy at Kirkwood for Girls 21st century 2015-2016 Afterschool Program
STUDENT INFORMATION (ALL INFORMATION MUST BE ENTERED. IF NOT, THE APPLICATION WILL BE REJECTED)
Student First and Last name
Your answer
Do they have a sibling that you are also enrolling?
Has you student previously been enrolled in the 21st Century Program at Ivy Prep?
Grade
Required
Mailing Address
Your answer
Homeroom Teacher
Your answer
Birthdate
Your answer
Age
Your answer
Lunch Status?
Ethnicity
Required
Students lives with:
Medical Needs: (allergies, medications, diet, etc.)
Your answer
Check box if legal restrictions are in effect
Parent/Guardian Email Address
Your answer
Parent/Guardian First & Last Name
Your answer
Parent/Guardian Contact Numbers (specify cell,home or work)
Your answer
Additional Parent/Guardian First & Last Name
Your answer
Additional Parent/Guardian Relationship to child ( mother, father, grandparent)
Your answer
Additional Parent/Guardian Contact Numbers (specify cell,home or work)
Your answer
#1 Emergency Contact First & Last Name (This person is authorized to pick up your scholar)
Your answer
#1 Emergency Contact Contact Number
Your answer
#2 Emergency Contact First & Last Name (This person is authorized to pick up your scholar)
Your answer
#2 Emergency Contact Contact Number
Your answer
#3 Emergency Contact First & Last Name (This person is authorized to pick up your scholar)
Your answer
#3 Emergency Contact Contact Number
Your answer
PROGRAM POLICIES
Parents/Guardians, please read each policy carefully.
Student Pick Up- I understand that when I pick up my child, I must sign them out with the 21ST CCLC Staff. Once i retrieve my scholar I should not interrupt the classrooms in any way to ensure student safety and respect the enrichment taking place.
Attendance Policy- I understand that 21st Century requires scholars to stay in the program until 6:30pm at least four days a week. If I can not commit to the attendance policy, I will be removed from the program.
I agree to the the expectation for good behavior in the 21st Century Afterschool Program. Students who refuse to follow the procedures outlined in the Student Handbook will not be allowed to continue in the program. Parents/Guardians will be contacted if a child misbehaves. Chronic misbehavior may result in dismissal from the program.
FIELD TRIP APPROVAL
Parents will be notified prior to these events. I give permission for my child to participate with the 21st Century Field Trips and activities. I release Ivy Prep Academy at Kirkwood for Girls and the 21st Century Program fro any liability in the unlikely event of an injury or accident.
TRANSPORTATION
Signatures
By your signature on this document, you hereby agree and consent that your child may participate in the 21st Century Community Learning Centers Program. You have been informed of the policies and procedures of the program, and understand that no medical expenses will be paid in connection with any injury incurred while participating in the activities of this program.
Name of Parent/Guardian: By typing your name below, this serves as your signature for the above statement.
Parent/Guardian Signature: Date:
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