21st Century After-School Academy Application 2018-2019
Placement is based on funding, staffing, availability and a first come first serve basis.
Student Last Name *
Your answer
Student First Name *
Your answer
Student School ID #
Your answer
Name of person completing the form *
Your answer
Relationship to child *
Student School *
Student Current Grade *
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/CodeofConduct2017-2018-final%20v.3.pdf
Do you agree to the Behavior and Discipline Agreement? *
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? *
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 *
21st Century Surveys 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 *
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? *
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