Henry County Afterschool Enrichment Program Registration Form 2023-2024

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Pleasant Grove Elementary

**Enrollment in the Henry County Afterschool Program is subject to space availability.

Notification of acceptance in the Afterschool Program will be completed within 5 business days at the time of registration. Parents will receive an email with a welcome packet and the student's start date. Space can be limited at some sites. Registrations beyond the enrollment limit 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 23-24 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 Afterschool Enrichment Program 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 Afterschool Enrichment Program 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 Afterschool Enrichment Program? A medical authorization form will need to be submitted to the Afterschool Program 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 Afterschool Enrichment 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 Afterschool Enrichment 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 Afterschool Enrichment 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 Afterschool Enrichment Program staff in understanding and caring for your child. *

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

Yes

Required

If the answer to the above question is "NO", please specify what additional accommodations your child would require during the Afterschool Enrichment Program.

Weekly tuition is $50.00 a week per student ($33.50 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. *

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

Required

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 family. *

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

Required

The Afterschool Enrichment 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 Afterschool Enrichment 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 Afterschool Enrichment 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 Afterschool Enrichment 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 Afterschool Enrichment 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 Afterschool Enrichment 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 Afterschool Enrichment 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 Afterschool Enrichment Program 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. *

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