2021-2022 After School Program Application-Rabun County Community of Learners    
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Student Last Name *
Student First Name *
Homeroom Teacher *
Grade *
Birthday *
MM
/
DD
/
YYYY
Address *
Lunch Status *
Special Needs (allergies, medications, diet, etc.) *
Ethnicity *
Student Lives With *
Transportation from After School *
Please let us know if any pickup or legal restrictions are in effect.
Please list any siblings who are also applying.
Parent/Guardian #1 *
Parent/Guardian #1 Phone Number *
Parent/Guardian #1  Email *
Parent/Guardian #2
Parent/Guardian #2 Phone Number
Emergency Contact
Emergency Contact Phone Number
Student success is a top priority.  In order to maximize student learning, all students are expected to conduct themselves in a manner that promotes a  positive learning environment. Good behavior is essential. Students who interrupt the learning environment will be dismissed from the program. *
If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the participant. I understand that I will be responsible for any transportation charges and medical expenses incurred. *
In order for students to get the maximum benefit of the program, the students are required to attend four out of five days each week.  Students who do not could be dropped from the roll. *
Medication taken by students during after school hours must be delivered by parents in the original bottle before it can be administered.   *
I hereby give my consent to the school district's 21st Century Afterschool Program  to take the participant's photograph during program activities, to be used for education and public relations purposes in conjunction with the school district's 21st Century Program.   *
I give my consent to the school district and the 21st Century Afterschool Program to share the participant's student records with each other for purposes  of providing educational support and assistance. *
I give my consent to the school district and the 21st Century Afterschool Program to obtain my child's lunch status if it is not provided above. I understand this information is required as part of acceptance into the program. *
Parents will be notified prior to field trips if they occur. I give permission for my child to ride the school bus on all 21st Century Field Trips and activities. I release Rabun County Schools and the 21st Century Program from any liability in the unlikely event of an injury or accident. *
The After School program will follow all RCSS procedures in regards to COVID-19, including mandatory quarantine if needed. *
By your signature on this document, you hereby agree and consent that your child may participate in the 21st Century After School Program. You have been informed of the policies and procedures of the program, and understand that no medical expenses will be paid in connection with any injury incurred while participating in the activities of the program. *
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