APPLICATION (k-12)
Application for our after-school program. We are trying to make the application process faster for our families.

On the Activities portion please fill out only your child's grade level and pay close attention to the activities dates. If you have more than 1 child attending our FREE after-school program you will have to fill it out twice.

Homework/Tutoring is held from 3:30-4:30 each day, unless 2 hours of tutoring which can be provided. Enrichment classes (see below) will be held from 4:30-5:30 each day. If your student ONLY attends from 3:30-4:30 for tutoring, they must be picked up at 4:30 in the Elementary Office. The office staff will contact your student’s teacher when you arrive. Activities may change days depending on student needs!

High School students who attend the program for tutoring or enrichment classes or both are required to come to the cafeteria each day to sign in and go to the Elementary office to sign out if you are leaving earlier than 5:30. Please do not leave campus without first signing out. All student car riders will be picked up at the cafeteria and all bus riders will need to depart at the designated area.
If you are a High School Student is being picked up at 5:30, you must go to the elementary office by the cafeteria.


Email address *
Is your child allowed to be photographed? (photos could be used on the Jessieville website, newspaper, or other media). *
What Grade is your child in? *
Required
DOB *
MM
/
DD
/
YYYY
Child's First name *
Childs Last name *
Address *
Parent Phone number *
Is it OK to send you info and reminders through...
check all that Are a YES
Health Information
If you have no allergies or other health info that we might need just put NA.
Allergies *
Other health problems we should be aware of
Transportation
Select one for the week. Parents must be present at the stop you select or the students will be brought back to the school.
Pick one *
Required
Enrichment Activity
All students will have 15-30 min of Homework time with a licensed teacher to help as needed. If you want your child to receive 2 hours of tutoring/ homework help pleas mark below. All enrichment activities changes every 6-10 weeks and this starts a new session if your child wishes to remain in the program we will need to be notified. You and your child will be notified of the changes We will try to have a survey to update any new information/ for the new sessions applications.
Tutoring and homework help 3:30-4:30
1 Hour tutoring only
2 Hour tutoring
1 hour tutoring / Enrichment Activity
Monday
Tuesday
Wednsday
Thursday
Due to a District-wide Staff Meeting, all students will be bused to MT. Tabor Church Up 298 on the second Wednesday of each month. They will feed the students, help with homework and do a lesson/games. The students will be bused back to school for the regular transportation schedule. This is for the 2nd Wednesday of the Month Only. If for some reason this date changes you will be notified. *
Required
Signature *
By electronically signing you are approving this form.
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