Neighborhood House Elementary After School Program Fall 23
Elementary Afterschool at Neighborhood House takes place Monday - Friday, MMSD dismissal to 6 pm. Fall programming begins on Monday September 11 and runs to December 15.

Afterschool consists of time for academics/homework help, enrichment activities, field trips, and gym/outside time. 

Students not walking/bussing can arrive/be dropped off from MMSD school dismissal until 4pm.

Pick-up takes place from 5 - 6 pm. 

Busing is available for students attending Franklin/Randall Elementary Schools. Afterschool is open to youth ages 7 to 5th grade (limited space for 6 year olds. 5 year olds can NOT enroll due to childcare licensing).

All afterschool programming is FREE of cost.

Neighborhood House also offers monthly Fun Friday events for youth and Off Day Programming.

Please contact Angel at angel@neighborhoodhousemadison.org with any questions!


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Email *
Youth First Name  / Primer nombre del niño *
Youth Last Name / Apellido(s) *
Date of Birth / Fecha de nacimiento *
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/
DD
/
YYYY
Youth Age / Edad *
Gender / Género *
Pronouns *
Grade for 2023 School Year / Grado para el año escolar  2023 *
Name of School / Nombre de escuela *
Parent/Guardian Name #1 (First and Last) /  Nombre y apellido del padre/madre/tutor *
Parent Cell Phone #1 / Número telefónico *
Address (Dirrecion) *
Parent/Guardian Name #2 (First and Last) /  Nombre y apellido del padre/madre/tutor
Parent Cell Phone #2 / Número telefónico
Parent Email #2
Afterschool takes place Monday 1-6pm and Tues - Fri 2-6pm. Please indicate all days your child will attend: / El programa va lunes 1:15-6pm y martes-viernes 2:30-6pm. Por favor, indica los días que su hijo/a va a asistir: *
Required
Transportation to Neighborhood House. My child(ren) will: / Transporte a Neighborhood House. Mi hijo/a:
If you indicated that your child will taking the bus, please contact your child's teacher and front desk staff as soon as possible to let them know they need a bus stop change.
Randall students take the Purple route to Orchard and Mound Street. Franklin Students take the Teal Route to Mound and Orchard St.
AUTHORIZATION FOR PUBLICATIONS I give permission for Neighborhood House Community Center and local publications to use my child’s name as well as photographs of and quotes from my child to be published on Neighborhood House’s social media, website, and newsletter and/or in local news stories related to Neighborhood House.    /    Doy mi permiso que Neighborhood House Community Center usa el nombre de mi hijo/a, se puede tomar fotos y citar mi hijo/a en publicaciones en las redes, sitio de web, y otras publicaciones impresas y en las noticias locales relacionadas con Neighborhood House.
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WALK HOME AUTHORIZATION By signing this below, I authorize my child to walk/bike home and understand and agree that the program will not assume any responsibility or liability once my child has left the facility.    /    Con mi firma abajo, yo autorizo a mi hijo/a para salir del programa de Youth Camp y regresar a casa a pie o por bicicleta. Entiendo y estoy de acuerdo que el programa y Neighborhood House no asumen la responsabilidad de mi hijo/a el momento que él/ella ha salido las instalaciones.
FIELD TRIP AUTHORIZATION: By signing below, I give my child permission to participate in all program activities and field trips pertaining to Neighborhood House Afterschool. Field trips will travel either by foot, or by Madison Metro bus. In the event that I do not want my child to participate, I understand that I must contact Neighborhood House Community Center staff.          /       Con mi firma abajo, doy mi permiso para que mi hijo/a participe en todas las actividades y excursiones que pertenece al programa Neighborhood House. Durante el programa los participantes se trasladarán a pie y por buses de Madison Metro. En el caso que no quiera que mi hijo/a participe en las actividades y el programa, entiendo que tengo que comunicárselo con los empleados de Neighborhood House Community Center.
PICK-UP AUTHORIZATION Please list the names and phone numbers of people who are allowed to pick up the youth from Neighborhood House Community Center other than their parents/guardians. / Por favor, darnos los nombres y los números telefónicos de las otras personas que estén permitidas de recoger su hijo/a de Neighborhood House Community Center.
Please list any health/physical concerns: / Preocupaciones de salud física del niño *
Please list any allergies/dietary restrictions: *
Does your child have an IEP? *
Does your child have a 504 plan? *
Please list any emotional/behavioral concerns: *
City of Madison Sampling Questions / Preguntas de muestreo para la ciudad de Madison
The City of Madison requests the following information - identities will not be disclosed. PARTICIPATION IS OPTIONAL and you only need to fill out once per year.

La Ciudad de Madison solicita la siguiente información: las identidades no serán divulgadas. La participación es opcional.
Please describe your race/ethnicity (please check all that apply) / Por favor, describe su raza (cheque todo que aplique)
Please check one / Por favor, elige uno:
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How many people in your family have a disability? / ¿Cuántas personas en su familia tiene una discapacidad?
Do you live in a family maintained by a female single head of household? / ¿Usted vive en una familia que está mantenida por una mujer soltera cabeza de familia?
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Please list FAMILY SIZE and INCOME LEVEL using the chart below: / Por favor, coloca el tamaño de la familia y el nivel de ingresos anualmente de la familia
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I have participated in a Neighborhood House event or program in 2023:  / He participado en un evento o programa de Neighborhood House en el 2023
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