Lake Holcombe After-School Enrollment 2017
IMPORTANT INFORMATION - READ CAREFULLY BEFORE YOU BEGIN...
It will take approximately 15 minutes to complete this form for each student.
Incomplete forms CANNOT be saved or submitted.
Personal information cannot be saved or used for multiple students.
Each student must be entered individually.
If you press "BACK" at anytime, this will ERASE all information you've entered to that point.
This form can be completed on a mobile device, however the formatting is 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.
Please type your email address with care as it will be used to contact you in case of emergencies.
Even one small typo in email will make it unusable.
Thank you taking the time to enroll online. We hope to simplify the process for next year using this year's data.
We truly appreciate your feedback and always strive to improve the After-School experience for families.
Your input and suggestions are always welcome!
Email address *
Additional Email (Work, other parent, etc.)
Your answer
First Name *
Your answer
Last Name *
Your answer
Address & City *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
2017-18 Teacher *
Grade *
*
First and Last name(s) of Sibling(s) Enrolling
Your answer
Days Attending *
Required
I understand there will be NO After-School Program during Parent/Teacher conferences. There will be NO After-School Program when school is cancelled for any reason. I am invited to a student showcase near the end of each quarter. The last day of After-School Program for this school year is Thursday, May 10, 2018 *
Requested Start Date *
Getting Home *
Walkers - 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 with one emergency contact.) Van - List details for driver here.
Your answer
Student Strengths (Check all that apply.)
Excels
Struggles
Math
Reading
Social Studies
Science
Classroom Behavior
Social Skills
Attendance and/or Being on Time for School
Father / Guardian
First Name *
Your answer
Last Name *
Your answer
Address & City *
Your answer
Place of Employment *
Your answer
Mobile Number *
Your answer
Home Number *
Your answer
Work Number *
Your answer
Mother / Guardian
First Name *
Your answer
Last Name *
Your answer
Address & City *
Your answer
Place of Employment *
Your answer
Mobile Number *
Your answer
Home Number *
Your answer
Work Number *
Your answer
Emergency Contact
First Name *
Your answer
Last Name *
Your answer
Mobile Number *
Your answer
Home Number *
Your answer
Work Number *
Your answer
Clinic/Hospital *
Telephone Number *
Your answer
Name of Doctor or Primary Care Provider
Your answer
Medical Conditions of Student *
Required
Condition Triggers
Your answer
Signs or Symptoms to watch
Your answer
Consent to emergency medical care for my student if I cannot be reached immediately. *
Additional Medical Notes
Your answer
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. If I am unable to access any of these options, I will ask for a special form requesting a call in the event of a cancellation. 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. *
Enrollment *
Donations *
Reason for requesting sponsor...
Your answer
After School Program Policies- please read and sign at bottom
After-School Program Policies

Registration Fee
$10.00 registration fee per student must be paid before student may begin attending After-School Program.
Registration fee should be paid at Open House (8/31/17) for those students starting the program on Sept. 11, 2017
Recommended Donation
PROJECT SOAR – Support, Opportunity, Achievement, Responsibility
Once registration is paid, instead of daily fees, students and families are part of PROJECT SOAR! The recommended donation for After School Program is $50 per student per year. Our goal is for every family to have a sponsor at this level. Your donation is tax deductible and will help us to continue to offer programming. We will help match local sponsors with families unable to make the recommended donation.

Schedule
Monday – Thursday September 11, 2017 – May 10, 2018 (approximately 123 days). Students who participate in After-School Program will have a wide variety of exciting opportunities. The following is a sample of our daily schedule.
There will be NO After-School during P/T conferences unless a "special session" is offered.

Time Activity Place
3:20 Recess/games Playground/Classrooms
3:40 Snack Elementary IMC
3:55 Homework/study skills/reading Classrooms
4:30 Academic Enrichment (activities!) varies
5:20 Activity Wrap-up Walkers Depart (Earlier mid-winter for light)
5:25 Bus and van depart
5:30 All Students Must Be Picked Up

Staff
Coordinator, Teachers, Leaders, & High-School Helpers.

Cancellations
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.

Transportation
Bus and school van transportation will be provided only for those with no other option. Transportation is a privilege, and misbehavior will not be tolerated. Students being transported will leave at 5:25pm. We cannot assure that all students will be home before 6:00pm as the length of the route depends upon how many students are using transportation.

Records
Student records will be kept confidential. Parent/Guardian must inform staff promptly of any changes to medical information, or allergies.

Behavior
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 program. School rules of conduct apply during After-School Program.

Calls
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.

Snack
Suitable snacks will be served daily to children who participate in the After-School Program. Students are not allowed to bring their own snack, with the exception of students with special dietary needs.

Emergencies
School procedures will be followed.

Dress Code
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 some voluntary trips and activities.

Medications
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 picture may be taken for the purpose of media coverage for the CLC program and I agree to allow these photographs, videotapes and audiotapes to be used for all media purposes including 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.

Electronic Signature - I have read, understand, give consent, and agree to all After-School Program policies and procedures. I will stop in at the Open House to meet the Coordinator and pay registration. *
Your answer
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