H.Y.P.E. After School Program Application
H.Y.P.E. After School Programs Application
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Email *
Today's Date *
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Student's Last Name *
Student's First Name *
Student's Date of Birth *
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Age *
Grade for 2025-2026 School Year *
Race *
Gender *
Address *
City *
State *
Zip Code *
School Student Attends *
Sibling Name
Sibling School
Sibling Grade
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Parent/Legal Guardian Name *
Cell # *
Work #
Home #
Parent /Guardian Email Address *
Parent/Guardian Employer *
Emergency Contact 1 Name *
Emergency Contact 1 # *
Emergency Contact Name 2 # *
Emergency Contact 2 # *
Emergency Contact Name 3 # *
Emergency Contact 3 # *
If your child has any FOOD ALLERGIES, please list below.  *
Does child carry an Epi Pen?
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Release of Information: Do you authorize Sumter School District or Liberty STEAM Charter School to release to the H.Y.P.E. After School Programs, all educational records, discipline records, and/or any other pertinent information for my child's participation in the HYPE Program.  The confidentiality of all information will be protected by the entity to which it is released and will not be further disseminated. *
Required

Student Agreement

Welcome to HYPE. This program is designed to help you help yourself. Our staff will not do your work for you but will assist you in developing the skills you need to become an independent thinker. Self-discipline, self-respect, regular attendance, and participation in HYPE activities are the key elements to your success in our program. Your responsibilities and student code of conduct are outlined below.

Responsibilities:

I understand that I must bring my books and all other work materials.

I understand that I have a set time for completing my homework. If I finish before time is up, I will ask for more work.

When I need help with my homework, I will ask for it.

I will have my homework reviewed by a staff member before leaving to go home.

I will cooperate with staff and do my best every day.

I will work toward my own self-development.

Student Code of Conduct:

I agree to show respect for myself and others.

I agree to enter the building and classroom quietly.

I agree to do my work quietly and conduct myself with dignity.

I agree to respect the program’s equipment, supplies and property.

I agree to return borrowed items to their proper places.

I agree to help keep the site clean by picking up after myself.

I agree to no candy, gum, alcohol, drugs, smoking, radios, video games, cellphones, hats, sagging pants, running, shouting, fighting, or cursing while at the program site.

I agree to notify the program director and/or staff if I have a problem with a student or person in the building.

I understand and agree to abide by the terms of this agreement. I understand that if I violate any part of this agreement I will not be allowed to participate in the program for a given time period and my parent/legal guardian will be notified.

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Parent Agreement

Tips on supporting your child’s education!

 Contact school day teachers and program staff regularly to discuss your child’s progress.

Attend school functions with your child often.

Express an interest in your child’s academic achievements and encourage good grades.

Praise your child daily for his/her efforts.

Let your child know that you believe in his or her ability to do well. Have high expectations and communicate these expectations to your child frequently.

Discuss report cards with your child. Acknowledge positive accomplishments and talk about ways you can work together to improve in areas needing improvement.

Monitor your child’s attendance in both school and the after-school program.

Encourage reading and writing at home. Ask your child to read aloud to you at least once daily.

Get involved in both school and after school program activities.

Set clear rules and study time at home and enforce them.

Help your child gain the strength to overcome fears and insecurities in order to positively cope with stress.

Attend mandatory HYPE parent meetings.

Tell your child daily good things about him/herself in order to help him/her develop high self-esteem and a healthy, positive self-image.

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Family Information: Parent/Guardian Legal Name *
Parent/Guardian Date of Birth: *
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Status: *
Highest Education Level Completed:
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Average Monthly Income
Household Members: Name/Age *
Do any student in the household receive free/reduced lunch? *
Do you receive EBT and/or AFDC, Medicaid, or WIC? Please specify the type of assistance *
What other programs does your child participate in?
List all adults (18 & older) who are allowed to pick up your children from HYPE and their relationship to the student. *

Limited Power of Attorney

 

If a serious emergency occurs it may be necessary for medical professionals to assist your son/daughter before the staff is able to contact you or your designated emergency contact person. Emergency medical care will be provided if you sign this authorization for medical treatment. 

I give the Site Director of the HYPE After School Program  limited power of attorney to act in my absence for my child,  to receive the necessary medical treatment in case of an emergency, illness, accident or injury.

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Pre-Existing Medical Conditions (i.e. allergies, blood transfusion, surgery, asthma, diabetes, etc) for child. *
Medication(prescribed by a doctor that my child is presently taking.
Health Insurance Company Name & Policy Number
Child's Doctor (Name & Phone Number *

Permission Slip for Activities and Trips

My child has my permission to participate in the program activities and trips for the current school year. I release the M.H. Newton Family Life Enrichment Center and all of its agents from any type of legal action regarding my child’s participation in this program.

State your name

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Photo/Public Relations Release Form

 

I, do hereby give the HYPE After School Program (or its authorized designee) the right and permission to copyright and publish the photo, Video, and/or quote in which my child may be included either wholly or partly for marketing, public relations and media Advertisements.

State your name

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