Chieftain Clubhouse Student Application

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If you would like for your student to be part of Chieftain Clubhouse, complete the application below.

Student Name *

First and last name

Student Grade *

Parent/Guardian Name *

First and last name

Parent/Guardian Email

Parent/Guardian Cell Phone # *

Emergency Contact Name (Other than Parent/Guardian listed above) *

Emergency Contact Phone # (Other than Parent/Guardian # listed above) *

Chieftain Clubhouse after-school program pick-up authorization & release:

The following person(s) to pick-up my child from the Chieftain Clubhouse after-school program. I understand that my child will only be permitted to leave with a parent/guardian or the person(s) listed below:

The following person(s) may pick-up my student from Chieftain Clubhouse after-school program (Name & Phone #): *

Chieftain Clubhouse pick-up agreement:

I understand that the pick-up time for my student is at 5:00P.M. If my student is not picked-up on time, they will be removed from the after-school program until the end of the quarter. Enter your name below to show that you agree:

Enter your name below to show that you agree with the Chieftain Clubhouse pick-up policy *

Medication & First Aid Policy:

A parent/guardian will be called to pick-up a child who is sick or injured. Medications will not be administered without written permission from the parent/guardian. The parent/guardian must bring the medication in an original prescription pill bottle prescribed to the student and given written instruction as to how the student takes the medication.

If your student takes medication during 3:10-5:00, let us know the name, dosage, and how it is taken below:

Chieftain Clubhouse general rules:

1. Show respect to all students, staff, equipment, and property.
2. Keep your hands, feet, head, and other body parts to yourself at all times. Fighting, hitting, biting, theft, and destruction of property, etc. WILL ABSOLUTELY NOT BE TOLERATED.
3. Students will use appropriate language at all times.
4. Students attending Chieftain Clubhouse will cooperate and participate with all club activities.

You and your student enter your names below to show that you have read and agree to follow these general rules:

Enter parent/guardian name & student name below to show you agree to follow the above general rules: *

3 strike policy:

At Chieftain Clubhouse, we adhere to a 3 strike policy in which a student will receive:
1. A verbal warning
2. A written warning (parent/guardian will be called to pick up student for the remainder of the day)
3. Write-up (parent/guardian will be called to pick up student for the remainder of the quarter

You and your student enter your names below to show that you have read and agree to the 3 strike policy:

Enter parent/guardian name & student name below to show you have read and agree to the 3 strike policy: *

Immediate Dismissal:

The following actions will result in immediate dismissal:
1. Any child that runs from the staff will be removed from the program. If staff cannot convince the child to return, the school resource officer/police will be called.
2. Any child who harms himself or another student (physical or verbal).
3. Any child who abuses staff will be removed (physical or verbal).
4. A site director has the right to dismiss a child at any time, the student must be picked up, or they will be escorted home by the school resource officer.

You and your student enter your names below to show that you have read and agree the following actions will result in removal from the after-school program:

Enter parent/guardian name & student name below to show that you have read and agree these actions will result in immediate dismissal: *

Parent/guardian code of conduct:

Parent(s)/guardian(s), you are expected to follow the program rules and treat the staff with respect. All program and/or staff issues, comments, or concerns should be directed to the site director. Any child whose parent verbally or physically abuse staff will be removed from the program. This includes sarcasm, criticism, yelling, screaming, and/or negative comments directed at staff and/or other parents. The school resource officer/police will be called to remove any parent who appears out of control.

Parent/guardian enter your name below to show you have read and agree to follow this code of conduct:

Parent/guardian enter name below to show that you have read and agree to follow the code of conduct: *

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