21st Century After-School Academy         Application 2019-2020
Placement is based on funding, staffing, availability and a first come first serve basis. IF  YOUR CHILD IS ENROLLED YOU WILL RECIEVE A WELCOME LETTER AND TRANSPORTATION INFORMATION. **IF YOUR CHILD IS NOT ENROLLED THEY WILL BE PLACED ON A WAIT LIST UNTIL A  SPOT BECOMES AVAILABLE.**  Submitting this form DOES NOT GUARANTEE placement in the program.
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Student Last Name *
Student First Name *
Student ID #
Student's daytime teacher
Last Name of person completing the form *
First Name of person Completing the form *
Relationship to child *
Please provide us with an email for future correspondence
Student School *
Student Grade for 2019-2020 school year *
Behavior and Discipline Agreement
In an effort to provide a productive learning environment, all students will be expected to follow the rules and procedures of the NECSD Code of Conduct.  https://www.newburghschools.org/files/district/documents/CodeofConduct2019-2020final%20v.3.pdf
Do you agree to the Behavior and Discipline Agreement? *
Required
Medical Consent
In the event of a medical emergency,  every attempt will be made to reach/contact parent/guardian first. First aid will be administered by a the nurse or another qualified professional.  If further medical treatment is necessary, 911 will be called. I authorize NECSD's 21st Century Program to obtain emergency transportation and treatment in the event that I  am not available.
Do you agree to give Medical Consent? *
Required
Attendance Policy
I understand that the 21st Century After-School Academy operates Tuesdays, Wednesdays, and Thursdays for two hours after school. I understand that my child(ren) are expected to attend all three days weekly. I understand that my child will ride the bus or other approved school transportation to approved functions or activities in the program. I also know that if attending a field trip outside of the program location I will be notified in writing.
I understand and agree to the attendance policy *
Required
21st Century Survey And Data Collection
The federal grant requires the NECSD 21st Century After-School Academy to engage all participating students in various anonymous age appropriate  state and independent agency surveys in an effort to analyze program effectiveness. IT also mandates  that student records pulled using ID numbers  only be made available to the state for reporting purposes.
I give my child(ren) permission to participate in all 21st Century Surveys and for Data to be used for reporting purposes *
Required
Authorization to Participate
I agree to all of the NECSD's 21st Century After-School Program's policies and procedures. I realize that it is a voluntary program and is not a required district activity. I also Agree to support my child's learning progression by adhering to the items contained in the 21st Century Family Handbook  
Do you agree to allow your child to participate? *
Required
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