City of Potlatch Afterschool Program 2020-21 Registration Form

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This Program serves students in grades 6-12 in Potlatch School District #285. Please fill out a separate form for each youth enrolling in the Program. We must have a completed Registration form in order for your student to attend the Afterschool Program.

This year's Program will be held at the former Potlatch VFW Hall (735 Pine St) Monday through Thursday from 3:00-6:00 p.m. We will allow both A & B groups in the Program every day, however, we will be maintaining social distancing and preventing intermingling between groups. Due to COVID-19 social distancing protocols, we will not be offering transportation to or from the Program at this time.

The Afterschool Program is closed on school holidays, school breaks, and emergency closures.

For more information about the Program, please contact Melissa Smith at 208-892-4032 / melissasmith@potlatch.com or Bridget Bailey at 208-874-7014 / bzgirlid@gmail.com

Student's Name: (First, Middle, Last) *

Student EDUID Number (if known)

School Attending: *

Potlatch Elementary School

Potlatch Jr/Sr High School

Home School

Other:

Student's Date of Birth *

YYYY

Grade: *

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

Physical & Mailing Address for Student: *

Parent/Guardian Name *

Parent/Guardian Phone Number *

Parent/Guardian Email Address

Student Medical and/or Allergy Information. Please list any allergies to food or medication, chronic illnesses, physical limitations, and/or medications the student may take.

Sign-Out/Release Information. Please list persons (besides a parent/guardian) including phone numbers for those whom you give permission to pick up your student from the Program

Instructions for Student Release *

Picked up at the Program (735 Pine St) by parent/guardian or person authorized above. Students will not be allowed to leave the site unless picked up by an authorized adult. If someone else will be picking up the student, a note must be sent to the Program leader for that date. Students must be picked up by 6:00 p.m.

Release to attend practice/meeting for school sport or group. (Please provide a list of practices/meetings, as well as release times for each, and update with the Program as needed.)

Walk/Bike home at 6:00 p.m.

Other:

Required

Emergency Contact Information. In the event of an emergency, please provide the name, relationship, and phone number of two people we may contact who know your student and can take full responsibility of your child, should you not be available. *

Emergency Information. Please place a check mark in each box to indicate that you have read and agree to the following. *

If your student comes to the Afterschool Program site and is found to have a temperature or other potential symptoms of COVID-19, they will be isolated and you will be contacted to come pick them up immediately.

I agree that in the case of illness or injury, medical care may be given to my student, in the event that I or the persons designated cannot be reached. I agre to pay for any medical expenses that occur.

In the event that I cannot be reached in an emergency, I hereby give my permission to the physician/hospital to secure proper medical treatment for my child.

Required

Parent/Guardian Consent. Please place a check mark in each box to indicate that you have read and agree to the following. *

I give my consent to the City of Potlatch Afterschool Program to photograph/video tape/audio tape my student and to use such pictures and/or stories in connection with any of their work without consideration for compensation of any kind, for articles, marketing purposes, and for presentations, and I do release the City of Potlatch Afterschool Program from any claims whatsoever which may arise in said regards.

I give my consent for my student to use the computer and internet under the guidelines of the Potlatch School District #285 policy “Computer & Internet Acceptable Use Policy” (available on the District’s website).

I give my consent to the City of Potlatch Afterschool Program, Potlatch School District #285, and the Idaho State Department of Education to share confidential information and work together in providing services for my student. This information may include test/assessment results, academic progress reports, absences, disciplinary action records, IEP’s, and medical information pertaining to medical conditions and medications. This information will remain confidential.

I give my permission for my child to attend all field trips of less than 5 miles related to after school activities. Longer field trips will require a separate permission form.

I give my consent for my child to attend the City of Potlatch Afterschool Program and participate in its activities. I also understand and accept that volunteers, including other parents, college students, high school students, and members of the community will assist in the program.

Required

Parent/Guardian Signature. I have read the above form and my typed name below stands for my signature demonstrating that I have provided my consent for my child to participate in the City of Potlatch Afterschool Program under the terms described above. *

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