Henry County BASE (After-school) Registration Form 25-26

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MT. CARMEL ELEMENTARY

**Space at certain sites may be limited. If enrollment exceeds capacity, additional registrations will be added to a waiting list. Participation in the Henry County B.A.S.E. (after-school) program depends on available space.

Email *

After submitting this registration form, you will receive an email confirming its submission. The email confirmation of submitting this registration form does not guarantee your child a spot in the program. However, based on available space, within seven business days, you will receive a follow-up Welcome Email confirming acceptance into the B.A.S.E. (after-school) program. This email will include important details such as after-school policies and payment information. Space may be limited at certain locations, and registrations exceeding capacity will be placed on a waiting list. *

I acknowledge I have read the above statement regarding registration and enrollment limits.

Required

Student's LAST Name *

Student's FIRST Name
*

Student's Grade Level for 25-26 School Year *

Anticipated Start Date (Please note that start date may be determined by waiting lists/enrollment limits) *

YYYY

Mother/Guardian's Full Name *

Mother/Guardian's Email Address *

Mother/Guardian's Cell Number *

Accept text messages at the above number? *

Yes

Required

Mother/Guardian's Work Number *

Father/Guardian's Full Name *

Father/Guardian's Email Address *

Father/Guardian's Cell Number *

Accept text messages at the above number? *

Yes

Required

Father/Guardian's Work Number *

Child resides with:

Both Mother and Father

Mother

Father

Legal Guardian

Foster Parent

Are there any custody issues in which the program staff should be aware? Please make sure legal documents are given to the B.A.S.E. (after-school) program administration staff to support custody arrangements. *

If you or another parent/guardian is a full-time benefitted Henry County Schools employee, please provide the following: Employee's full name, Employee ID number, and work location. *

Name of Emergency Contact (first and last name) and best contact phone number. This person is in case custodial parent(s)/legal guardian cannot be reached. *

Please list allergies (food, medication, bees, etc.) *

Does your child require an Epi-Pen for the above allergies? If yes, please provide the B.A.S.E. (after-school) program administration staff with the student's Epi-Pen prior to first day of attendance.

Yes

Are there any medications that your student will be required to take during the B.A.S.E. (after-school) program? A medical authorization form will need to be submitted to the B.A.S.E. (after-school) administration staff prior to medication being distributed. Please list medications, dosage, and time of dosage. If your child requires an inhaler, please provide the Afterschool Enrichment Program with the student's inhaler prior to the first day of attendance. *

Medication will not be distributed to students during the Afterschool Enrichment Program (including aspirin or cough drops) unless a Medical Authorization Form is completed by custodial parent/legal guardian and on file with the Afterschool Enrichment Program staff. Please obtain Medical Authorization Form from the program's Site Coordinator. *

I acknowledge I have read the above statement regarding medications.

Required

If a medical emergency arises, the B.A.S.E. (after-school) program staff will first attempt to contact parents. If the parents cannot be reached, the staff will contact the emergency contact designated on registration form. If the emergency is such that immediate hospital attention is necessary, emergency personnel will be called for further assistance/medical treatment. *

I acknowledge I have read the above statement regarding medical emergencies.

Required

Please list all persons authorized to pick up your child from the B.A.S.E. (after-school) program including parents and legal guardians. Only authorized persons can pick up students from the program with proper identification. Individuals not on the release list authorized by the enrolling parent will not be allowed to pick-up any child from the B.A.S.E. (after-school) program. Note: ONLY the enrolling parent can make changes to the authorized pick-up list. It is highly recommended to list more than 1 person on this list. *

Tell us about your child. Please include information which would be helpful to the B.A.S.E. (after-school) program staff in understanding and caring for your child. *

Is your child fully potty trained and able to use the restroom independently without assistance or accommodations? *

Yes

Required

Is your child able to participate in a classroom setting with 17 or more students without special accommodations? *

Yes

Required

If the answer to either of the previous 2 questions is "NO", please specify what additional accommodations your child would require during the Afterschool Enrichment Program.

Weekly tuition is $60.00 a week per student ($43.50 a week per student for HCBOE full-time employees) and is due the Friday before the week of service. If payment is not received on Friday, a $5.00 late fee will be charged to the weekly tuition. Students may be dismissed from the Afterschool Enrichment Program for non-payment of weekly tuition. Weekly tuition can be paid by check, money order, or by using the online service, www.myschoolbucks.com. Please be aware that participation on a drop-in basis is not available. If your child participates in the CAPS program, please provide an updated scholarship to the program's Site Coordinator as soon as possible. Credits will ONLY be given for a child that is out due to illness for two or more consecutive days. A doctor’s excuse will need to be provided to the Site Coordinator to receive this credit.

Tuition Schedule: Click here Tuition Schedule

I acknowledge I have read the above statement regarding weekly tuition, late payments, modes of payments, and CAPS participation.

Required

Financial matters: The BASE after-school admin team, including the bookkeeper, is authorized to discuss tuition-related matters with the following individual(s): *

Student Concerns: The BASE after-school admin team is authorized to address student-related matters, including but not limited to behavioral concerns, with the following individual(s): *

There is a one-time registration fee of $25.00 that is due upon approved registration in the program and is non-refundable. This is a yearly fee per student. *

I acknowledge I read the above statement regarding the yearly registration fee.

Required

The B.A.S.E. (after-school) program is open according to the official school calendar of Henry County Schools. The program is closed during school holidays and inclement weather days; however, we do operate on early release days. *

I acknowledge I have read the above statement regarding program closures.

Required

Discipline must be a collaborative responsibility between the B.A.S.E. (after-school) program staff, student, and parent. Students are expected to follow all established rules that apply during the regular school day, per the Henry County Schools Code of Conduct. Behavior that causes unsafe situations, or that undermines the ability of program staff to maintain a safe and secure environment will be addressed. Disciplinary actions may be imposed ranging from temporary removal from an activity to suspension/dismissal from the program, depending on the severity of the infraction. Severe infractions may necessitate immediate dismissal on a first offense. *

I acknowledge I have read the above statement regarding behavior expectations and discipline procedures.

Required

Homework time is included in the B.A.S.E. (after-school) program's daily schedule and although staff is available to assist, we are unable to offer one-to-one tutoring services. Students are expected to work on homework during the allotted time unless permission is granted from parents to work on homework at home. If a student is granted permission to complete homework at home instead of during the B.A.S.E. (after-school) program, please provide a signed/dated handwritten note to the program's Site Coordinator. The student will then be issued an alternative activity that will help reduce the temptation of being a distraction to other students who are completing their homework. *

I acknowledge I have read the above statement regarding homework completion.

Required

The B.A.S.E. (after-school) program closes promptly at 6:00 pm. Parents are required to pick-up their student before the program ends. Failure to do so will result in a charge of $1.00 per minute (as of 6:01 pm), which will be added to the next tuition payment. Multiple late pick-ups will lead to a student being removed from the program. Custodial parents/legal guardians are required to keep all contact numbers current. It is highly recommended to list more than one person as an authorized pick-up. *

I acknowledge I have read the above statement regarding late pick-ups.

Required

Withdrawal from the program requires a one-week written notice. All balances must be paid in full before withdrawing from the program. Henry County B.A.S.E. (after-school) program also reserves the right to disenroll a student for non-payment, behavioral issues and/or late pick-ups. *

I acknowledge I have read the above statement regarding withdrawal from the program.

Required

On occasion, the B.A.S.E. (after-school) program shows G/PG movies. Please indicate below if your student is able to view PG movies. *

My student may view PG movies.

My student may NOT view PG movies.

Required

Do you give permission for your child to be photographed and/or video recorded for social media accounts and/or program documentation? *

Yes, I give my permission to have my student appear in media/social media coverage.

No, I do not give my permission to have my student appear in media/social media coverage.

Required

It is the responsibility of the parent to complete all forms accurately and to maintain records as changes in phone numbers, medical history, guardianship or other pertinent information occur. Parents should provide their child with a signed and dated note addressed to the B.A.S.E. (after-school) Site Coordinator if a change in the daily transportation will be made since verbal requests cannot be honored. A handwritten note needs to be sent to your child's homeroom teacher, as well. *

I acknowledge I have read the above statement regarding accuracy of records.

Required

Name of parent(s) completing registration form. ONLY enrolling parents can make changes to the enrollment form. *

Communication:

Please use the link below to enroll in the REMIND communication. This is an important tool used to receive updates from the B.A.S.E. (after-school) admin team regarding safety, possible severe weather, dismissal location changes, etc.

https://www.remind.com/join/3fb3g2

I acknowledge I have read the above statement regarding REMIND communication.

Required

Overdue Balances:

**Please confirm your account status by speaking with your after-school program’s admin team or bookkeeper, or by checking the IC Parent Portal. Outstanding balances will result in your child’s application being placed on a waiting list until all fees are paid in full.

I acknowledge I have read the above statement regarding overdue balances.

Required

MT. CARMEL ELEMENTARY

**Space at certain sites may be limited. If enrollment exceeds capacity, additional registrations will be added to a waiting list. Participation in the Henry County B.A.S.E. (after-school) program depends on available space.

For any questions or concerns, please contact your after-school program's administrative team via email. Allow one business day for a response.

V. Hodges: vivian.hodges@henry.k12.ga.us

M. Butler: michelejacksonbutler@henry.k12.ga.us

I acknowledge I have read the above statement regarding registration and enrollment limits.

Required

A copy of your responses will be emailed to the address you provided.

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