Henry County Afterschool Enrichment Program Enrollment Form 2022-2023

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Hickory Flat Elementary

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

Email *

Student's Last Name *

Student's First Name *

Student's ID Number

Student's Date of Birth *

YYYY

Grade Level for 2022-2023 school year *

Pre-K

Kindergarten

First Grade

Second Grade

Third Grade

Fourth Grade

Fifth Grade

Anticipated Start Date *

YYYY

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

Mother/Guardian's Full Name *

Mother/Guardian's Cell Number *

Accept text messages on the above number? *

Yes

Mother/Guardian's Work Number *

Mother/Guardian's Email Address *

Father/Guardian's Full Name *

Father/Guardian's Cell Number *

Accept text messages on the above number? *

Yes

Father/Guardian's Work Number *

Father/Guardian's Email Address *

Child resides with *

Legal Guardian's Name *

Legal Guardian's Email Address *

Legal Guardian's Cell Number *

Accept text messages on the above number? *

Yes

Legal Guardian's Work Number *

Are there any custody issues in which the program staff should be aware? Please make sure legal documents to ASEP staff to support custody arrangements. *

If you or someone in your household 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.) *

Does your child require an Epi-Pen for the above allergies? *

Yes

N/A

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. *

Yes

N/A

Please list medications, dosage, time of dosage *

Please list all persons authorized to pick up your child from the Afterschool 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 able to pick-up a child from the Afterschool Program. Note: ONLY the enrolling parent can make changes to the authorized pick-up list. *

Tell us about your child. Please include information which would be helpful to ASEP 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

If the answer to the above question is No, please specify what additional accommodations your child would require during the Afterschool Program?

Weekly tuition is $50.00 a week per student ($33.50 a week per student for HCBOE full-time employees) and is due on 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 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. *

I acknowledge I have read the above statement regarding weekly tuition and late payments.

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

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

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. *

I acknowledge I have read the above statement regarding afterschool availability.

Discipline must be a collaborative responsibility between the ASEP staff, student, and parent. Students are expected to follow all established rules that apply during the regular school day and 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.

Homework time is included in the program 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. *

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

Medication will not be distributed to students during ASEP (including aspirin or cough drops) unless a Medical Authorization Form is completed by custodial parent/legal guardian and on file with ASEP staff.

I acknowledge I have read the above statement regarding medicine.

Clear selection

If a medical emergency arises, the ASEP staff will first attempt to contact parent. If the parent cannot be reached, the staff will contact the emergency contact designated on enrollment 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.

The Afterschool 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 $1.00 per minute (as of 6:01 pm), which will be added to the next tuition payment. Multiple late pick-ups can lead to a student being removed from the program. Custodial parents/legal guardian are required to keep all contact numbers current. *

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

Withdrawal from the program requires a one-week written notice. Henry County Afterschool 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 withdrawing from program.

On occasion the Afterschool Program shows G/PG movies. Please indicate below if your student is able to view movies. *

My student may view both G and PG movies.

My student may ONLY view G movies.

My student may NOT view G or PG movies.

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.

Notification of acceptance in the Afterschool Program will be completed within 48 hours at the time of registration. Parents will receive an email with a welcome packet and the 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.

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 Site Coordinator if a change in the daily routine will be made since verbal requests cannot be honored. *

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

Name of person completing the enrollment form and relationship to student. *

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