Jefferson Jr.Sr. Club Registration
Second Semester Clubs , January 9th - May 15th, 2023.

Submit one form per Student (you may always resubmit to add additional sessions at a later time)

Semestre 2 Clubes , 9 de enero - 15 de mayo de 2023.

Envíe un formulario por estudiante (siempre puede volver a enviarlo para agregar sesiones adicionales en un momento posterior)

21t CCLC REGISTRATION FORM- Parent/Guardian Authorization


Medical Information

“I understand that JHS after school/summer programs do not administer any medication to participants.  I understand that JHS after school/summer programs are not responsible or liable for any issues or problems that are related to medication adherence.  I understand that it is my responsibility to ensure that my child receives his/her medication.”  ____________(Parent/Guardian Initials)  Please list the type of medication that the participant is responsible for:  _______________


Educational Programs

The District is committed to ensuring that all eligible students, including those with disabilities, have an equal opportunity to participate in non-academic and extracurricular programs and activities.  If your student requires an accommodation to participate in the program(s) described above, please contact Weston Scott at 303-982-6056.



“My child has my permission to participate and engage in all 21st CCLC program activities (which may include field trips – walking/riding, transportation and other activities which may involve certain risks) except as otherwise noted: ___________________________________”   ______ (Parent/Guardian Initials) 


Release of Liability

“In consideration of my child’s voluntary participation in the JHS 21st CCLC Program and related activity, I hereby release and discharge the Jefferson County School District and their successors, heirs, assigns, directors, officers, employees, supervisors, agents, attorneys and representatives, from any and all actions, causes of action, claims, demands, losses, damages, costs, attorney fees, judgments, liens, indebtedness and liabilities whatsoever, known or unknown, suspected or unsuspected, pas, present or future, with regard to all matters that could have been raised in an action on the merits regarding the aforementioned activity in which I and my child have elected to voluntarily participate.” __________ (Parent/Guardian Initials) 



In the case of an EMERGENCY, JHS will first call 911 to ensure your child’s safety.  JHS will then immediately contact the parent/guardian on the emergency form. “In the event that a parent/guardian cannot be reached in an EMERGENCY, I herby give permission, to the physician selected by JHS to secure treatment, hospitalize and order injection, anesthesia or surgery for my child at my expense.”  __________ (Parent/Guardian Initials) 


Sharing of Information

“I give permission to JHS to release information about my student to professionals from the following organizations as well as give these organizations permission to share this information with program staff regarding involvement and participation in their programs. I understand that the identity of my student will be protected and my student’s name and student id number will not be released with this information. This information includes CSAP and CELA scores, GPA, special education, IEP, and ESL status, gender, ethnicity, Free and Reduced lunch status, attendance, and discipline incidents. __________ (Parent/Guardian Initials) 



 “I give permission to JHS to administer to my child a survey about student attitudes during the course of the 21st CCLC program. I understand that if I want to review the survey prior to it administration to students in the program, I may do so by contacting my child’s school 21st CCLC coordinator. I understand that my student’s identity will not be included in any way on the survey itself or in the reporting of survey results. The survey will cover the current school year”. The organizations with whom the student survey response information may be shared are:


1. Jefferson County Public School District

4. Colorado Department of Education


“I understand that my student has the option to choose to not take the survey, and exercising this option will not in any way affect his or her participation in the program. I understand that this school information will not be further released in any form that identified or would allow identification of my student without my further written consent. I understand that these records are protected under the federal and state regulations governing privacy of personal information, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that there are limits to this confidentiality in the event that there is risk of eminent harm of oneself or another person or in the event that there is reason to suspect that a child is being physically, emotionally, or sexually abused or neglected.  It is required by law that any individual that has knowledge of such abuse or neglect report it to the proper authorities.  I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it.”  __________ (Parent/Guardian Initials)  

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Email *
Student's school email address *
Student Name (first and last)  Nombre y apellido del estudiante *
Student's Grade/Grado de estudiante *
Parent/Guardian Name / Nombre de padres *
Parent/Guardian Phone number / Numero de telefono de padres *
Do you give permission for your student to participate in after school clubs? ¿Permite que su estudiante participe en clubes extracurriculares? *
Most Clubs begin September 12th, Monday-Friday from 3:15-4:30 pm, besides Middle School sports which begin August 22nd- Enrollment in After School Clubs Program is limited based on space availability- Grade level restrictions apply to certain activities.- Submit one form per student (you may always resubmit to add additional sessions at a later time) - Filling out this registration form does not guarantee that your student will be accepted.- Your student will receive a registration confirmation email within 72 hours of submission.      Los clubes comienzan el 12 de septiembre, de lunes a viernes de 3:15 a 4:30 p. para agregar sesiones adicionales en un momento posterior) - Completar este formulario de registro no garantiza que su estudiante sea aceptado.- Su estudiante recibirá un correo electrónico de confirmación de registro dentro de las 72 horas posteriores al envío.
Are you interested in joining any of the clubs listed below? Start dates and times will be announced soon!

¿Estás interesado en unirte a alguno de los clubes que se enumeran a continuación? ¡Las fechas y horarios de inicio se anunciarán pronto!
Friday/Viernes *
What clubs would you like to see offered that are not currently on the list?  ¿Qué clubes le gustaría que se ofrecieran que no están actualmente en la lista?
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