After School Program Registration Form-Session 3
The Butler 21st Century Afterschool Program, session 3 will start April 1st and will run for  8-10 weeks

Students are given a healthy and hearty snack each day 
Students who enroll in programs are expected to participate in the program from 2:50-5pm. 
Students do not have to enroll every day (Monday -Thursday) of the week, but are expected to stay from 2:50 - 5pm on the days they are participating and must remain in the building.  

Head to the school's website for a longer description of each program- https://www.lowell.k12.ma.us/domain/2710 

Transportation is NOT provided.
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  • I give permission for my child to attend the 21st Century program at the Butler School, if my child is not eligible for transportation I will be responsible to pick up my child at 5:00 pm.

  • I also understand that my child is responsible for remaining in the school building and needs to report directly to the after-school programs designated area at dismissal time

  • I give my child permission to participate in the above-listed course/program(s) offered through the Lowell Public Schools Extended Time Program.  Permission is also granted for my child to travel on trips for special programs that are offered through the Lowell Public Schools Extended Time Program. 

  •  The Lowell Public Schools Extended Time Program is not responsible for any injury or accident that may occur during the above-listed course/program(s) or due to the falsification of any information provided on this form. I give permission for emergency medical treatment to be administered to my child by qualified medical personnel in the event of an accident or injury.

  • I give permission for my child to be videotaped and/or audiotaped during participation in the above-listed course/program(s) conducted by the Lowell Public Schools Extended Time Program. 

  •  I understand that the footage (pictures, video, and sound) may be incorporated into materials that promote the Lowell Public Schools Extended Time Program.

 

This form needs to be completed by the parent/guardian
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Email *
First Name *
Last Name *
Student Address  *
Grade *
Date of Birth *
LASAID Number (lunch number) *
Gender
Homeroom Number

Parent or Guardian Contact Info (Name, Relationship, Phone Number)

 *
Parent or Guardian email
Emergency Contact Info (Name,Relationship, Phone number) 

 *

Does the student take any type of medication or have any medical condition that we should be aware of (medication, allergies, etc.)? 

If yes, please explain:

 *
How will the student get home?
 transportation is NOT provided

 *
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