Fillable 2020/2021 SUMMER & AFTER SCHOOL LIGHTHOUSE REGISTRATION -K- (City of Bridgeport)

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2020/2021 SUMMER & AFTER SCHOOL LIGHTHOUSE REGISTRATION -K- (City of Bridgeport)

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Student’s Name (s):
Gender: Race:
School:
SASID# Grade (Sept 2020)
DOB:
1. ________________________________ M F _____ ______________ ___________ ______ __________
2. ________________________________ M F _____ ______________ ___________ ______ __________
3. ________________________________ M F _____ ______________ ___________ ______ __________
4. ________________________________ M F _____ ______________ ___________ ______ __________
Home Address: _____________________________________________________________________________________________
City
State
Zip code
Part Time
Name of parent(s)/guardian: ________________________________ Home phone: ______________ Cell: ___________________
Employer: _____________________________ Work hours: _______ Full Time Unemployed
Employer Address ___________________________________________________ Work Phone:_______________________
Facebook Account Twitter
Account
Email Address: ___________________________________
Gross Yearly Household Income: _________________ Family Size: _____ Family Unit: Parent Parents Guardian
If I cannot be reached in the event of an emergency, please call:
Name: _____________________________________ Relationship: ____________________ Local Phone: _______________________
Address: ______________________________________________________________________________________________________
City
State
Zip code
Person(s) who have permission to pick your child up: (please send a note if this changes)
Name: ______________________________________ Relationship: ___________________ Local Phone: _______________________
Name: ______________________________________ Relationship: ___________________ Local Phone: _______________________
Name: ______________________________________ Relationship: ___________________ Local Phone: _______________________
I give permission for my child to receive emergency medical attention while attending the Lighthouse Program.
Signature of Parent(s)/Guardian: ______________________________ Date:________________________
Primary Insurance Carrier: ____________________________ Secondary Insurance Carrier: _____________________________
My child has the following medical conditions:________________________________________________________________________
Will any of these conditions hinder his/her ability to fully participate? Yes No
If yes, please explain: ____________________________________________________________________________________________
Physicians Name: __________________________ Address: _______________________________ Phone: ______________________
*Does your child have an Individual Education Plan (IEP) or Behavior Log during the school day? Yes No
*Does your child receive special services during the day, i.e. meet with a social worker, special education teacher, speech and language
therapist, etc.? Yes No May we discuss their IEP or special needs with appropriate school personnel? Yes No
My child needs medication during the course of the day: (if applicable) Type(s): ____________________ Time (s): ________________
I give permission for my child to be transported while attending regularly scheduled Lighthouse field trips.
Signature of Parent(s)/Guardian:______________________________ Date:________________________
In signing this form I certify that my child is a resident of Bridgeport and completed Kindergarten. I understand I am registering my child for a
low cost subsidized program that requires his/her full participation in the program and that unless an unforeseen emergency arises or special
consideration is made, I agree to pick my child up at the end of the program day 5:30 and no earlier. As such no child will be turned away based on
ability to pay. All program fees are recommended and not a requirement of enrollment/continued service. I agree to all the terms and conditions set forth
above including the Lighthouse Policy located below. I further agree that my child’s academic records, immunization records, and photos be available
as needed for specific purposes such as studies on the impact of after school programs on student achievement, publications, project videos and fund
solicitation. I authorize the district to release my child’s state assigned student (SASID#) to the Lighthouse Program for state reporting purposes. I am
aware a $25.00 NON-REFUNDABLE registration fee in form of a money order for each child registered is due at the time of registration
and that I am responsible for the weekly fee regardless of whether or not my child attends every week. By signing below I understand
and agree to the above information.
Signature of Parent(s)/Guardian: ______________________________ Date:________________________
Site Use Only - Must be completed when child is registered
Date Paid _______________ M. O. #__________________
Staff Initial ______ Amount Paid _________
Start Date______________
Summer Only_____ A/S Only _____ Both_____
-K- 5 GRADES ONLY
2020/2021 SUMMER & AFTER SCHOOL
LIGHTHOUSE REGISTRATION
Parent/Guardian Signature
Date
In addition to those policies and procedures outlined in the Operational Guidelines and the Lighthouse Policies and
Procedures Manual, the Lighthouse Program is establishing the following policy in writing. The Lighthouse Program, its
contracted agencies and site staff reserve the right to dismiss any child temporarily or permanently from the Lighthouse
Program should he or she fail to abide by Board of Education rules and/or Agency rules while attending the summer or
after school program. The Lighthouse Program agrees to review all data presented and follow up with appropriate
individuals before a decision is made in either of the above instances. Should the action warrant
immediate response, the Lighthouse Program reserves the right to do so.
Behavior Policy Discussed with Parent
REGISTRACIÓN PARA EL PROGRAMA DE LIGHTHOUSE DE
VERANO Y DESPUÉS DE CLASES 2020/2021 PARA GRADOS K - 5
Además de las pólizas y guia de procedimientos de la directrices operativas y el manual de procedimientos del programa
“Lighthouse”, el programa Lighthouse establece por escrito la siguiente póliza. El progama Lighthouse, sus agencias
contratadas y el personal se reservan el derecho de dar de baja a cualquier niño temporalmente o permanentemente del
programa Lighthouse si no cumple con las reglas de la Junta de Educación y/o las reglas de la agencia mientras estate
asistiendo al programa de verano o el programa después de clases. El programa acuerda revisar todos los datos presen-
tados y dar seguimiento con el personal apropiado antes de tomar una decisión en cualquiera de las instancias menciona-
da arriba. Si le acto amerita una acción inmediata, el programa se reserva el derecho de hacerlo.
Póliza de conducta discutida con el padre/encargado ___________________________________________
Nombre del Estudiante(s): Sexo: Raza: Escuela SASID# Grado(2020) Fecha de
nacimiento
1. _______________________________ M□ F□ _____ _____________ ___________ _______ __________
2. _______________________________ M□ F□ _____ _____________ ___________ _______ __________
3. _______________________________ M□ F□ _____ _____________ ___________ _______ __________
4. _______________________________ M□ F□ _____ _____________ ___________ _______ __________
Dirección: _____________________________________________________________________________________________
Ciudad Estado Código Postal
Nombre de los padres/encargado:_______________________________ Teléfono: ______________ Celular: ________________
Empleador/Patrono: _____________________Horas de Trabajo: _______ Tiempo completo Mitad de tiempo Desempleado
Dirección del Empleador____________________________________________ Teléfono del trabajo_____________________
Facebook Twitter Correo electrónico: _______________________________________
Ingreso bruto annual por familia: ____________ Miembros de la familia: ____ Hogar: Un padre Dos padres Encargado
En caso de una emergencia, favor de llamar a:
Nombre: _____________________________________ Relación del niño: ________________ # de teléfono: _____________
Dirección: _____________________________________________________________________________________________
Ciudad Estado Código postal
Persona(s) que tiene permiso a recoger al niño después del programa: (favor notifique si los nombres cambian)
Nombre: ____________________________________ Relación: _____________________ Teléfono Local: ______________
Nombre: ____________________________________ Relación: _____________________ Teléfono Local: ______________
Nombre: ____________________________________ Relación: _____________________ Teléfono Local: ______________
Le doy permiso al programa “LIGHTHOUSE” para que mi hijo/a reciba atención médica.
_______________________________________ __________________________
Firma del Padre/Encargado Fecha
Seguro Primario: _____________________________________ Seguro Secundario: ___________________________________
Mi hijo/a sufre de las siguientes condiciones médicas:______________________________________________________________
Podrán algunas de estas condiciones impedir su participación en el programa? Sí □ No □
Sí, favor de explicar: ________________________________________________________________________________________
Nombre del médico _____________________________________ Teléfono del médico_______________________________
¿Tiene su hijo/a un plan individual educativo, un diario de conducta para el dia escolar? Sí □ No □
¿Recibe su hijo/a servicios especiales durante el día escolar, tal como reunirse con la trabajadora/o social, un maestro/a de educación
especial o el terapista de habla? Sí No ¿Podemos discutir su IEP o necesidades especiales con el personal apropiado de la
escuela? Sí No
Mi hijo/a necesita medicamento durante el día:
Tipo de medicamento: _______________________ Hora(s): _____________________________
Yo doy permiso para que mi hijo/a sea transportado mientras asiste a las excursiones regulares de Lighthouse.
______________________________________ ___________________________
Firma del Padre/Encargado Fecha
Al firmar ésta forma certifico que mi hijo/a es residente de Bridgeport. Entiendo que estoy registrando mi hijo/a para un programa
bajo costo subsidiado que requiere su plena participación en el programa a menos que surja una emergencia imprevista o se
hace una consideración especial, me comprometo a recoger a mi hijo/a al final del programa a las 5:30 y no antes. Ningún niño
será rechazado aunque usted no pueda ser los pagares. Además, estoy de acuerdo con todos los términos y condiciones expuestas
arriba incluyendo la Póliza de Lighthouse. Todas las tarifas son recomendadas no un requisite. También estoy de acuerdo que los
expedientes académicos de mi niño y las fotos tomadas están disponibles para observar el crecimiento académico del estudiante, así
como publicaciones, proyectos de video y solicitación para fondos. También autorizo el distrito a dar el SASID# de mi niño/a al
Programa de Lighthouse con propósitos de reportaje para el estado. Estoy consciente de una cuota de inscripción no reembolsable
de $25.00 tiene que ser pagada en forma de un giro postal para cada niño(a) registrado(a) en el momento de la inscripción y que soy
responsable de la cuota semanal asista o no asista el niño(a) al programa cada semana.
______________________________________ ___________________________
Firma del Padre/Encargado Fecha
Póliza de Conducta
Firma del Padre/Encargado Fecha
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20202021 SUMMER & AFTER SCHOOL LIGHTHOUSE REGISTRATION -K- (City of Bridgeport)

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Completed 2 August 2020

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