Parent Application - The Perch Afterschool Program
Welcome to Afterschool at The Perch (ASAP)!
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Program Description
Our goal is to provide a safe place for students in 3rd-9th grades to learn, grow and connect with one another and supportive adults. (Older students can email Angie Martin at angette@gmail.com to apply to be a student mentor.) Participants will meet at The Market Building at The Perch on Fridays after school until 5:30pm. Students eat a snack and have a chance to play games and do crafts. The program is run by Imani Wheeler and Angie Martin with support from high school peer mentors and other adult volunteers.

Families are encouraged to pay $10 a day, though they can pay more or less based on what they are able to contribute. Families can also support the program by providing snacks and volunteering their time. Click here for payment information. Email Angie at angette@gmail.com about providing snacks or volunteering.

The program will begin this fall on Friday, September 13th.
Student Information
Please list all of your children that you give permission to participate in the program on Wednesdays and or Fridays after school.
Child’s full name *
Child’s grade *
Child's date of birth *
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Child's age *
What is the best way to get in touch with your child/children? *
Second child's name
Second child's grade
Second child's date of birth
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Third child's name
Third child's grade
Third child's date of birth
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Does your child/children have any special needs? (such as allergies, medications, diet restrictions, medical conditions etc.) *
Does your child/children qualify for free or reduced lunch? (for grant reporting purposes) *
Parent/Guardian Information
Parent/guardian #1 - full name *
Parent/guardian #1 - phone number *
Parent/guardian #1 - email *
Parent/guardian #1 - home address *
Parent/guardian #1 - relationship to student *
Does the child/children live with parent/guardian #1? *
Parent/guardian #2 - full name (optional)
Parent/guardian #2 - phone number  (optional)
Parent/guardian #2 - home address (optional)
Parent/guardian #2 - relationship to student  (optional)
Does the child/children live with parent/guardian #2? (optional)
Clear selection
Emergency contact - full name (NOT a parent. Please list a friend, neighbor or family member) *
Emergency contact - phone number *
Emergency contact - relationship to student *
Is this person authorized to pick up the student from the program? *

What would you like us to know about your child/children?

 *
Parent/Guardian Permission and Liability Release
Parents and Guardians - Please read the information in each of the boxes below. Choose YES if you agree and NO if you do not agree.

I give permission for the participants listed on this application to take part in The Perch Afterschool Program activities at the Red Barn and the Perch and which may include off-site events such as trash pick-ups around town or a walk to Arnold Park. *
If a medical emergency arises, The Perch Afterschool Program staff will take all steps to ensure the safety of the participant and will call, if necessary, a public emergency vehicle for transportation to an emergency facility. I understand that I will be responsible for transportation charges and medical expenses incurred. *
I agree that if a health condition exists now or in the future that would impact the participation of those listed on this application, I will notify the The Perch Afterschool Program  Program Coordinator. *
I, on behalf of my child, in consideration of his/her participation in The Perch Afterschool Program, hereby release The Perch, The Perch Afterschool Program and New Neighbors Network, its officers, employees and agents, and any other people officially connected with this program, from any and all liability for damage to or loss of personal property, sickness or injury from whatever source, legal entanglements, imprisonment, death, or loss of money, which might occur while participating in this program. *
Required
I give my consent to The Perch Afterschool Program and the organizations of which it is an affiliate (New Neighbors Network, The Perch) permission to take the participant’s photograph and video during program activities and to use photographs and videos in publications, displays, and advertisements or for any other purpose The Perch Afterschool Program deems proper at any time. *
I give permission for my child’s artwork, poetry or other work produced in The Perch Afterschool Program to be used for education and public relations purposes. *
Parent/Guardian Contract
Please read each statement below and check that you understand these key features of the Perch Afterschool Program.
The Perch Afterschool Program meets from 3:30-5:30pm on Friday afternoons and includes snack and enrichment activities. *
Required
Please share any scheduling needs your child might have. 

Program attendance is flexible, but we do need to know when to expect your child for planning purposes and when we should worry if they are not there!
The Perch Afterschool Program may communicate with my child’s school about my child’s academic, disciplinary, guidance, and/or behavioral performance. This information will only be used to support my child measure and program success. *
Required
I agree to make arrangements for my child to be picked up between 5:15-5:45 each Friday they attend.  *
Required
It’s important for program staff to know who is is coming each day, so I will let Imani or Angie know if my child/ren aren’t able to be there.  *
Required
The Perch Afterschool Program will use surveys, interviews and student records to evaluate individual progress and improvement, as well as to evaluate the impact of the program on students’ achievement and to obtain continued funding for the program. *
Required
In order to create a safe and fun environment for all, bullying, violence, weapons, theft, drugs, alcohol and vaping will not be tolerated at The Perch. Students who engage in these activities may be immediately suspended or expelled from the program. *
Required
Students are expected to listen, follow directions, and treat all program participants with respect. If a student has a hard time doing that, program staff members will meet with the student and/or their parent/guardian. If the issue is not resolved, the student may be suspended or expelled from the program. *
Required
Students should leave valuables at home. Program staff will not be responsible for keeping students’ items safe. If valuables are missing or lost, it is the student’s responsibility. Therefore, it is important that students do not bring items of value with them to the program. *
Required
How will your children get from the middle or high school to The Perch Afterschool Program, held at 1914 Madison Street Comer, GA. *
How will your child/children get home from The Perch when the program ends at 5:30pm on Fridays? *
Please list names and phone numbers of people who are allowed to pick up your child/ren. *
I give permission for The Perch Afterschool Program staff and/or volunteers to drive my child to and from The Perch Afterschool Program in their personal vehicles if needed. This is only an option in special circumstances and must be worked out directly with the program director. *
Parent/Guardian - Please type your name below to indicate that you have read and agree to the terms and conditions described above. *
Thank you for applying to The Perch Afterschool Program!
 Feel free to reach out to Angie if you have any questions. 516-413-9382, angette@gmail.com
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