Godfrey-Lee Public Schools 2021-2022 TEAM 21 After-School Program Application
Please fill out the form as follows. If you have any questions, please contact the following individuals:
ECC - Brittani Stickler (616) 438-5855 bstickler@godfrey-lee.org
Godfrey Elementary - Eric Mockerman (616) 438-5866 emockerman@godfrey-lee.org
Lee Middle - Sarah Robinson (616) 292-4136 srobinson@godfrey-lee.org
Today's Date: *
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2021-2022 School Attending *
Student's Legal FIRST Name *
Student's Legal LAST Name *
Student's Home Address (Street Address) *
Student Home Address (City) *
Student Home Address (Zip Code) *
Parent/Guardian Name(s) *
Parent/Guardian Cell Phone Number (please use this format: xxx-xxx-xxxx) *
Parent/Guardian Home/Work Phone Number (please use this format: xxx-xxx-xxxx)
Parent/Guardian Email *
Student Nickname (if any)
Student Grade (2021/2022 School Year) *
Student Birth Date *
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Student Age *
Student Gender *
Primary Language spoken at home *
For non-emergency communication, how would you prefer that we contact you? *
Please list any siblings applying for TEAM 21 and the school they attend (Note that separate applications are required for each student applying)
Emergency Contact Information
Please list at least two people who can be contacted if a parent cannot be reached in an emergency situation. To authorize additional individuals to pick up the student from the program, please fill out the Student Pick-Up section at the end of this application.
Emergency Contact #1 - Name & Relationship *
Emergency Contact #1 - Phone Number (please use this format: xxx-xxx-xxxx) *
Emergency Contact #2 - Name & Relationship *
Emergency Contact #2 - Phone Number (please use this format: xxx-xxx-xxxx) *
Transportation
*Please note that elementary students are permitted to walk home during the summer session ONLY.
Please indicate your preferences for mode of transportation home from TEAM 21: *
Bus drop off address if different from home address:
Student Race (can select multiple) *
Required
Student Ethnicity *
My child is in good health: *
She/he is restricted from: *
Please list any health concerns or other conditions that the TEAM 21 program staff should be aware of, including food allergies: *
Check this box if you would like to receive a follow-up call regarding the health concerns or allergies listed above.
I give permission for TEAM 21 to provide sunscreen, insect repellent, hand lotion or antibiotic (first aid) lotion as needed, if my child requests it. *
My child's immunization records can be found on file with my child's school: *
If a serious accident or illness occurs, I request that a representative of my child's school and/or the City of Wyoming Parks and Recreation Department contact me. If I cannot be reached, I request that they contact the physician named and that physician's instructions be followed to treat my child. The hospital, its agents, or a licensed physician, may administer the emergency medical treatment they deem necessary under the circumstances.
Child's Physician - Name and Phone Number: *
Insurance Provider and Policy Number: *
Preferred Hospital: *
Is there any court order which the TEAM 21 program should know of? *
If you have a restraining order, guardianship papers or name changes, please allow the TEAM 21 program to make a copy for your child's records. Please provide any relevant information:
During the school year and summer, it may be necessary to photograph, video or audio record my child for educational purposes. I grant permission to Wyoming Public Schools, Godwin Heights Public Schools, Godfrey-Lee Public Schools and the City of Wyoming to use my child's picture or likeness or a video or audio recording in any publication, multimedia production, display, advertisement or internet publication for any lawful purpose. *
In consideration of participation in the TEAM 21 program, for myself and on behalf of my child: (i) I hold Wyoming and Wyoming's elected and appointed officers and board members, employees, volunteers and insurance carrier(s) harmless from any claims for personal injury, property damage, or illness (including for example and without limitation, infectious disease exposure) that may be suffered by my child, me, any of my child's family members, or others that arise from my child's participation in the TEAM 21 program, even if due to the negligence, acts, omissions or statements of Wyoming and Wyoming's elected and appointed officers and board members, employees, or volunteers. (ii) I promise not to sue Wyoming and Wyoming's elected and appointed officers and board members, employees, volunteers or insurance carrier(s) for personal injury, property damage, or illness that may be suffered by my child, me, any of my child's family members, or others that arise from or during my child's participation in the TEAM 21 program, even if due to the negligence, acts, omissions or statements of Wyoming and Wyoming's elected and appointed officers and board members, employees, or volunteers.
TEAM 21 will be utilizing current waivers signed by the parent/guardian upon school enrollment for field trips, emergency medical response, photograph/audio/video/taping, and court orders. TEAM 21 will also be utilizing student data such as grades, attendance or discipline provided by the school district for student support and data comparison purposes.
Michigan daycare licensing regulations require us to notify you that care centers operating in school buildings, such as TEAM 21, may use school outdoor playgrounds for activities. Those school playgrounds may or may not comply with the Handbook for Public Playground Safety, PUB No. 325.
Parent Notification of the Licensing Notebook Requirement - Child Care Organizations Act, 1973 Public Act 116- All child care centers must maintain a licensing notebook which includes all licensing inspection reports, special investigation reports and all related corrective action plans (CAP). The notebook must include all reports issued and CAPs developed on and after May 27, 2010 until the license is closed. This center maintains a licensing notebook of all licensing inspection reports, special investigation reports and all related corrective action plans. The notebook is available to parents for review during regular business hours. Licensing inspection and special investigation reports from the past two years are available on the Bureau of Children and Adult Licensing website at www.michigan.gov/michildcare.
Additional Comments Regarding My Child:
Child T-Shirt Size:
Clear selection
Should there be an opportunity to do so, are you interested in volunteering with TEAM 21?
Clear selection
Parent/Guardian Handbook Link - To streamline our enrollment process, we are including a link to our Parent/Guardian Handbook immediately below. Please contact your child's TEAM 21 Site Coordinator if you would like to receive a paper copy!
Childcare licensing rules require that we maintain a record from each family that you received the Parent/Guardian Handbook. *
My signature below indicates that I understand and agree to all terms listed above. By typing my name below, I understand and agree that my electronic signature has the same legal effect as a manual signature. *
Thank you for completing this form. We will be in touch!
The TEAM 21 programs are made possible through a partnership between the City of Wyoming Parks and Recreation Department, Godfrey-Lee Public Schools, Godwin Heights Public Schools and Wyoming Public Schools. These materials have been developed with 21st CCLC funding through a grant awarded by the Michigan Department of Education.
Student Pick-Up - Additional Approved Individuals (OPTIONAL)
Complete this section only if you would like to grant permission for additional people (besides yourself and the Emergency Contacts you listed above) to pick up your child.
Name & Phone Number
Name & Phone Number
Name & Phone Number
Name & Phone Number
Name & Phone Number
Name & Phone Number
Name & Phone Number
Please note that any additions/deletions to the above list or to the emergency contact section on the application need to be made in writing to the Site Coordinator.
By typing my name below, I understand and agree that my electronic signature has the same legal effect as a manual signature.
Parent/Guardian Signature
Today's Date
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Thank you!
These materials have been developed with 21st CCLC funding through a grant awarded by the Michigan Department of Education.
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