2020-2021 Cornell After-School Registration
Funding provided by 21st Century CLC Grant
Please call 715-861-6960 for more information.


Please complete an enrollment form for each student
- Each enrollment takes approximately 15 minutes.
- Partial or incomplete forms cannot be saved.
- Pressing "BACK" at anytime, this will ERASE all information you've entered to that point.
- Mobile device will work. Formatting will be better on a traditional computer screen.
- Answer all questions with a red star. If there is no red star, you may leave the question blank.

Thank you for enrolling online.

Your input and suggestions are always welcome!
Email address *
Additional Email (Work, other parent, etc.)
I understand that Cornell After-School Program will be held at the Our Savior's Lutheran church in Cornell, that masks will be required, and that day-school protocol will be followed during programming. Elementary students will meet a leader at 5th street "E1" and walk safely together to the church each day. Middle School students will walk directly to the church at their final bell. Students are expected to have safe and respectful behavior at all times. *
Student First Name *
Student Last Name *
Student Address *
City *
Student Date of Birth *
2020-2021 Grade/Teacher (No PreK After-School) *
Bus Number / Driver *
Days Attending *
Pickup Time - All students must be out of the building by 5:45 each evening to allow for cleaning and sanitizing. *
Requested Start Date: Must complete by 8:00 p.m. Wednesday of the week prior to requested start date to allow time for processing. After-School begins a little later this year due to staff recruitment and training... Monday, September 14, 2020 *
No After-School Dates: I understand there will be NO After-School Program when school is cancelled for any reason. *
Getting Home *
Walk - List walking buddies here.
Picked Up - List approved adults and EXTRA contact info here if necessary. (No need to list parents as they are entered elsewhere along with one emergency contact.)
Ride Van - List details for driver here.
Clear selection
Student Strengths (Check all that apply.)
Social Studies
Classroom Behavior
Social Skills
Attendance and/or Being on Time for School
Father / Guardian
First Name *
Last Name *
Address *
City *
Mobile Number *
Home Number *
Place of Employment *
Work Number *
Mother / Guardian
First Name *
Last Name *
Address *
City *
Mobile Number *
Home Number *
Place of Employment *
Work Number *
Emergency Contact
First Name *
Last Name *
Mobile Number *
Home Number *
Work Number *
Clinic/Hospital *
Telephone Number of Clinic/Hospital *
Name of Doctor or Primary Care Provider
Medical Conditions of Student *
Condition Triggers
Signs or Symptoms to watch
Consent to emergency medical care for my student if I cannot be reached immediately. *
Additional Medical Notes
After-School Cancellations: A group email will be sent to primary addresses provided. If I have no email, I will be sure to check the school webpage, and Facebook. I understand that my electronic signature below shows my agreement with all After-School policies and procedures and provides my consent to all items listed on After-School forms. *
Donations Completely Optional - No Fees Required *
Optional Additional Information
Type Adult First and Last Name Below if you agree.
After-School Program Policies

NO Registration Fee!
There are no longer any After-School Program fees; only optional donations for participation and transportation.

PROJECT SOAR – Support, Opportunity, Achievement, Responsibility
Students and families are part of PROJECT SOAR! One donation option for After School Program is $50 per student per year. Our goal is for every family to have a sponsor at this level. We will help match local sponsors with families anonymously.

Monday – Thursday
September 14, 2020 – May 6, 2021. Students who participate in After-School Program will have a wide variety of exciting opportunities. The following schedule is a sample guideline.

Time Activity - Place
3:16 Walk to Homework / Skills Practice - Our Savior's Lutheran Church Classrooms
4:15 Snack - OSL Classrooms
4:30 Academic Enrichment - Rooms / Outdoors / Kitchen / Park / Etc.
5:20 Walkers & First Van Depart (Earlier mid-winter for light) Ripley Exit
5:30 Extended learning plus P.E. - Fellowship Hall / Outdoor as weather permits
5:45 Dismissal - Student Pick up (Ripley Street)

6:00 Special Classes & Events - See Community Education Brochure to Sign Up

Family Education Director, Site Coordinator, Academic Advisor, Teachers, Adult Leaders, & High-School Helpers.

School procedures will be followed. Be sure to provide up-to-date contact information and check Facebook, school webpage & email regularly when weather is changing.

Attendance / Communication
Notification of absence in advance is required. Any sport or extra-curricular activity which effects the After-School schedule or pick up of an enrolled student needs to be clearly communicated to staff prior to the start of said activities.

Van transportation will be provided only for those with no other option. One donation option is $30 per quarter. Students riding the van must comply with the rules as indicated in the student handbook. Transportation is a privilege, and misbehavior will not be tolerated. The first van route will depart beginning at 5:20 p.m. while the second route (if needed) will depart when the first returns and so on.

Student records will be kept confidential. Parent/Guardian must inform staff promptly of any changes to medical information, or allergies.

Excellent behavior is expected from all students. Students who display disruptive behavior will be given three written notifications and then will be dismissed from the program for a minimum of one week at a time. At staff discretion, some behaviors may result in automatic dismissal from program. School rules of conduct apply during After-School Program.

Students will be allowed to call home at the discretion of the site director.

Personal Items
If any personal item is seen by any After School Program staff as a distraction to program activities, that item will be placed in the CLC office until the end of the day. Students may not use cell phones or other electronic devices at After-School Program without prior consent from director.

Suitable snacks will be served daily to children who participate in the After-School Program.

School procedures will be followed.

Dress Code
Masks will be required until further notice. Students will spend time outside in the After-School Program, weather permitting. Children who are not properly dressed may miss outside activities. A wide variety activities are offered, some of which can get pretty messy. It is possible for clothes to get dirty or even stained during project times. After-School Program will follow the guidelines of the regular school day concerning weather.

Field Trips
Trips will be included in part of curriculum. Signing the permission page allows your child to participate in local trips. A separate form will be sent home for trips requiring transportation. Fees may apply for voluntary trips.

Staff does not distribute medicine of any kind.

● Permission to access the Internet and e-mail:
Your daughter/son will be permitted access to networked computer services with expectations to match school-day usage. (Please see student handbook – available on school website). The District uses a filtering system that generally blocks student access to inappropriate sites. If you do not want your student to be allowed this access, you must inform the CLC program, in writing, within 14 days after the date of enrollment.

● Permission to photograph, videotape and audio tape:
I understand that my child’s image may be captured at CLC program and I agree to allow these photographs, videotapes and audiotapes to be used for all CLC purposes including the CLC Webpage and FACEBOOK PAGE.

● Permission to participate in surveys and testing for data collections purposes:
I understand that my child may be asked to complete survey information and participate in testing regarding the CLC program for evaluation purposes and I agree to allow my child to participate in such.

● Permission to speak with school staff regarding child’s progress:
I understand that the CLC focuses on improving education and I agree to allow the CLC staff and school staff to exchange information, academic progress, and program planning at my child’s school regarding my child’s grades, conduct, and attendance records.

● Permission to attend After School field trips:
I understand my child may attend After School “walking” Field trips, and that separate permission slips will be sent home prior to field trips requiring transportation.
I have read, understand, give consent, and agree to all After-School Program policies and procedures. Type name of parent/guardian completing form. This will serve as your Electronic Signature. *
A copy of your responses will be emailed to the address you provided.
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