Armstrong 21st Century Afterschool Program Registration Form

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This free afterschool program is offered to students who reside in Bristol Township and are facilitated by Nita M. Lowey 21st Century Community Learning Centers and funded by the Pennsylvania Department of Education in partnership with the YMCA of Bucks and Hunterdon Counties and the Bristol Township School District.

Email *

Last Name of Student: *

First Name of Student *

Student's Date of Birth

YYYY

Age of Student: *

Fall 2022 Grade: *

6th Grade

7th Grade

8th Grade

Current Homeroom Teacher: *

Student Google Classroom Email Address

Student ID #

Name of Legal Guardian 1: *

Legal Guardian 1 Relationship to Child: *

Legal Guardian 1 Cell Phone Number: *

Legal Guardian 1 Home Phone Number: *

Legal Guardian 1 Email Address: *

Legal Guardian 1 Place of Employment: *

Legal Guardian 1 Work Phone Number: *

Legal Guardian 1 Preferred Method of Contact: *

Legal Guardian 1 Address Line 1: *

Legal Guardian 1 Address Line 2:

Legal Guardian 1 City *

Legal Guardian 1 State *

Legal Guardian 1 Zip Code *

Name of Legal Guardian 2: *

Legal Guardian 2 Relationship to Child: *

Legal Guardian 2 Cell Phone Number: *

Legal Guardian 2 Home Phone Number: *

Legal Guardian 2 Email Address: *

Legal Guardian 2 Place of Employment: *

Legal Guardian 2 Work Phone Number: *

Legal Guardian 2 Preferred Method of Contact: *

Legal Guardian 2 Address Line 1: *

Legal Guardian 2 Address Line 2

Legal Guardian 2 City *

Legal Guardian 2 State *

Legal Guardian 2 Zip Code *

Name of Primary Emergency Contact and Relationship to Student: *

Primary Emergency Contact Cell Phone Number: *

Primary Emergency Contact Email Address: *

Secondary Emergency Contact and Relationship to Student: *

Secondary Emergency Contact Cell Phone Number *

Secondary Emergency Contact Email Address: *

Please list the names of individuals that you authorize to pick up the student from in-person activities: *

I affirm that the above information is correct. I understand that my child must maintain routine attendance for the after school program. *

Yes

In the case of an emergency, if 21st Century Community Learning Centers staff is unable to reach the Parent, Legal Guardian or an Emergency Contact for the Student, we have no option but to call the police. (This applies to In-Person Programs Only) *

I agree to notify 21st Century Learning Centers staff of any changes to Emergency Contact Information.

Students being picked up must have a parent or guardian present by 4:50 p.m. Any students without a ride present at 5:00 p.m. will be required to board the 5:00 p.m. bus. Refer to the registration slides or BTSD website for bus stop information. Do you acknowledge this information?
*

Yes

21st Century Community Learning Centers do not have access to student health records. Please share with us anything we need to know about your child such as allergies and illnesses. *

The YMCA of Bucks County/Bristol Township Nita M. Lowey 21st Century afterschool programs provide a safe, pleasant, and educational environment for your child. With this goal in mind, 21st Century has instituted an Acceptable Behavior Code for all of its program participants. Along with our efforts, we need the children to help us create this environment by following some simple and effective rules. All parents and children are asked to agree to the Acceptable Behavior Code Policy: • I will respect others. 21st Century aims to teach the children that we work together to use words to communicate our feelings. Therefore, any physical aggression such as hitting, fighting, or shoving; verbal aggression such as name calling or rumor spreading; and/or non –verbal aggression such as intimidation, threatening gestures and deliberate exclusion from a group activity will not be tolerated. • I will listen and follow directions. • I will use appropriate language. • I will respect other’s feelings by having a positive attitude when speaking to them. • I will use my inside “voice” when talking to others. • I will ask permission of a teacher or monitor before leaving the group for any reason. Following these rules will enhance your child’s experience in our programs. All incidents will be handled following the 4-Step Progressive System (except for physical aggression or any form of violence.) All incidents will be handled as follows: 1. Verbal Warning 2. Written Warning/Parent Meeting 3. 1-Day to 3-Day Suspension 4. Dismissal from Program Physical aggression will result in an immediate 1 to 3 day suspension from the program. A parent meeting will be held. Repeat violent offenses will result in your child being dismissed from the program. Depending on the severity of the incident, 21st Century Staff reserves the right to immediately dismiss any child from the program. It is very important that all parents and children adhere to the guidelines of 21st Century Programs. Therefore, if you are late in picking up your child 3 times, you may be removed from the program. All parents and students must agree to the Acceptable Behavior Code Agreement in order to be registered for the after school programs. Please acknowledge that you have read and understood the Acceptable Behavior Code Agreement and understand that these regulations will be enforced. *

I understand that the Acceptable Behavior Code regulations will be enforced.

The YMCA of Bucks County/Bristol Township Nita M. Lowey 21st Century afterschool programs will adhere to all COVID safety rules based on the most current data for Bucks County and the State of Pennsylvania. The safety rules may include, but are not limited to, required mask wearing, social distancing, and reporting any COVID symptoms and/or illness. The COVID safety rules are subject to change in compliance with new mandates, adjust to trends or see troubling student and staff behaviors that need to be addressed. Failure to comply with all COVID safety rules will result in dismissal of the student from the program. Please acknowledge that you agree to comply to all COVID safety rules and that you understand that the student will be dismissed from the program for failure to follow required safety protocols. *

I understand that failure to follow COVID safety protocols will result in dismissal from the program.

Nita M. Lowey 21st Century Community Learning Centers may on occasion take pictures or video of learning center projects to be used for promotion of programs and for the historical documentation of the project. Please indicate below if you wish to allow your child to be photographed. *

Yes

21st Century Community Learning Centers are funded by the Federal Government, under the oversight of Pennsylvania Department of Education. 21st Century Centers are required to provide specific student data for all participants. This data includes report card grades, test scores, discipline and attendance records. This information is reported to both the state and federal governments to provide information regarding the success of federally funded after school programs. Additionally, this information and is used to determine the amount of money that will be allotted nationally for future funding of after school programs. PLEASE NOTE that student data is always reported using a randomly assigned student ID number. At no time is a student’s name or address used in reporting statistics. No one other than your child’s program teacher and the 21st Century Project Director will have access to your child’s information. All 21st Century employees are contractually bound to protect and honor student confidentiality. If you have any questions or concerns regarding this policy, please do not hesitate to contact the 21st Century office. Do you authorize the release of your child’s records to assist the 21st Century Grant staff in determining the success of your child/children’s 21st CCLC programs? *

Yes

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

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