Sunny View Elementary PEAK After School Application 2023-2024
The PEAK After School Program is a free program offered by PEAK (Polk Enrichment and Activities for Kids) a 21st CCLC program. PEAK After School details and policies can be reviewed at https://polkschools.org/after-school/ They are also posted at each site and available from the PEAK director.
Sign in to Google to save your progress. Learn more
Student First Name *
Student Last Name *
Student Birthday *
MM
/
DD
/
YYYY
Student Address *
Student Grade 23-24 School Year *
Parent/Guardian Name & Phone Number *
Parent/Guardian Email
How may we contact you?  *
Required
Parent/Guardian Name & Phone Number
Alternate Emergency Contact Name & Phone Number: (Cannot be Parent/Guardian)  *
 Does your student have any illnesses, medical conditions, and/or allergies:  *
Glossary of Terms
504 Plan: a plan developed to accommodate an academic setting for a student's disability. Students with a 504 Plan do not have a special education teacher. 

Title I: Title I services are provided to children who are failing, or most at risk of failing, to meet challenging State academic standards.
 
Special Education/ EC: Exceptional Children with IEPs (Individualized Educational Plans) receive services and accommodations/modifications for their disability.  

AIG: students perform or show the potential to perform at substantially high levels of accomplishment when compared with others of their age, experiences or environment.

ESL: English Second Language students may receive services to support the development of English Language Skills. ESL students have a primary language other than English and have learned English through school. 

 Does your student receive any of the following services?  *
Required
Are there other children in your home that also applied for PEAK After School? 

Each child needs their own application.

You may write "See (Other child's name)" in fields that may overlap on the application. 
 *
If YES, please list their names below
Pick-Up List
Guardians and Emergency contacts will be allowed to pick your student up from after school. Please list anyone 18 and older, who has your permission to pick up your child from After School.
Inform family and friends to be prepared to show ID. 
Students will not be released to anyone who is not listed below without the written/verbal permission of that child’s legal guardian.
Are there any other adults (18 or Older) you wish to add to your pick-up list? 
PEAK Program policies can be reviewed at  https://tinyurl.com/4jyd99zt 
You can contact PEAK Director, Tiffany Dennis, with any questions or comments at (828) 894-3051 or tdennis@polkschools.org
You grant permission for your student’s picture to be taken and possibly appear in local newspapers, as well as Polk County Schools websites and social media.
*
Please Explain If "Other" 
PEAK After School is a need-based program. 
 PEAK After School has an attendance requirement of at least 2 full days (pick up 5:45-6:00) or 6 hours per week. If you have split custody or another factor impacting your ability to meet this requirement please explain in the comments below  or call 828-894-1002  . 

If you have any need factors you feel weren't considered in the application please list them below or call 828-894-1002. 
Questions, Comments: 
By signing your name below and submitting this form you agree to all PEAK After School policies and Code of Conduct, which can be found under Policies on the PEAK web page. You also agree that PEAK After School staff may seek medical attention for your child in the result of an emergency. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Polk County Schools. Report Abuse
Google Forms