2021 Lake Holcombe After-School Enrollment
Funding provided by 21st Century CLC Grant
Please call 715-595-4241 Ext 249 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!
Sign in to Google to save your progress. Learn more
Email *
Additional Email (Work, other parent, etc.)
Student's First Name *
Student's Last Name *
Address *
City *
Date of Birth *
2021/22 Grade/Teacher *
First and Last name(s) of Sibling(s) Enrolling (Must complete enrollment form for each student)
No After-School Days - Bus Number / Driver *
Days Attending *
No After-School Dates: I understand there will be NO After-School Program when school is cancelled for any reason. *
Requested Start Date -- Must receive application 2 weekdays prior to requested start date. *
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 Bus - 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's First Name *
Father's Last Name *
Address *
City *
Mobile Number *
Home Number *
Place of Employment *
Work Number *
Mother's First Name *
Mother's 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 all addresses provided. If I have no email, I will be sure to listen to local radio stations, 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 *
Type Your 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 7, 2021 – May 19, 2022. Students who participate in After-School Program will have a wide variety of exciting opportunities. The following schedule is a sample guideline.

Time Activity
3:15 End of school day/Transition to After School - Homework/Skills Practice
4:00 Snack (will incorporate Monthly Character Trait discussion into this time)
4:30 Academic Enrichment - making learning fun with hands on activities
5:15 Physical Education - Group activities to get moving
5:45 Dismissal - Bus and van loaded and off/Walkers head home/Student pick 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.

Bus and van transportation is available upon request.

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 the 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. 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 newspapers, 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. *
Electronic Signature - I have read, understand, give consent, and agree to all After-School Program policies and procedures. Type your name below as consent. *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Lake Holcombe School District. Report Abuse