Fillable 21st Century Afterschool Program - 2020 -2021 REGISTRATION FORM

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21st Century Afterschool Program - 2020 -2021 REGISTRATION FORM

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Robstown ISD
21
st
Century Afterschool Program
2020-2021 REGISTRATION FORM
NAME OF STUDENT: (last)_________________________ (first)__________________________ (middle)_______________
STREET ADDRESS: (street)______________________________________________________________ (apt #) __________
CITY/STATE/ZIP: _________________________________________ DATE OF BIRTH: _________________ (age)______
GENDER: (male)____ (female)____ RACE: __________________________ SCHOOL: ___________ GRADE: _______
STUDENT ID #: __________________________ PRIMARY LANGUAGE: _________________________
TEACHER’S NAME ___________________________________________________________________________________
FATHER/LEGAL GUARDIAN (name)____________________________________________________________________
ADDRESS (street)_____________________________________ (city/state) _________________________ (zip)_________
EMPLOYER ________________________________________ (work phone) _________________
CONTACT (home phone) _________________ (cell phone) _________________
(email)______________________________
PLACE AN “X” ON YOUR PREFERRED WAY TO BE CONTACTED (hm phone) __ (wk phone) __ (cell/text) __
(email)__
MOTHER/LEGAL GUARDIAN (name)___________________________________________________________________
ADDRESS (street)_______________________________________ (city/state) _________________________ (zip)_________
EMPLOYER _____________________________________________________ (work phone) __________________________
CONTACT (home phone) _________________ (cell phone) _________________
(email)______________________________ PLACE AN “X” ON YOUR PREFERRED WAY TO BE CONTACTED (hm
phone) __ (wk phone) __ (cell/text) __ (email)__ HOW DOES YOUR CHILD NORMALLY GET HOME?
(school bus) ______ (city bus) ______ (walk)______ (gets picked up) ______ (other): ________________________________
WHO HAS PERMISSION TO PICK YOUR CHILD UP AT THE END OF THE DAY, BESIDES YOURSELF?
(name/relationship) _________________________________________________________ (phone)______________________
(name/relationship) _________________________________________________________ (phone)______________________
_____ I understand that if my child is supposed to be picked up and is not by the end of programming, the afterschool staff may
call Robstown PD. After three late pick-ups, my child may be excused from the program.
MEDICAL INFORMATION: Please list any special problems your child may have, such as allergies, illnesses, prescribed
medications, serious injuries, and/or hospitalizations:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
DOCTOR’S NAME: ____________________________________DOCTOR’S PHONE: ______________________
DOCTOR’S ADDRESS: (street)_________________________________ (city/state) _____________________ (zip)_______
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT: In case my child has an accident or sudden
illness,
and in the event I cannot be reached by phone, I hereby authorize a representative of AISD to refer my child to the physician
named above or seek appropriate medical care. AISD cannot be held responsible for any cost incurred:
PARENT/GUARDIAN SIGNATURE: ____________________________________________ (date)___________________
CONTACT IN CASE OF EMERGENCY AND PARENTS CANNOT BE REACHED:
(name/relationship) _________________________________________________________ (phone)______________________
RISD
RISD
(name/relationship) _________________________________________________________ (phone)______________________
AUTHORIZATIONS FOR (name of child): _______________________________________________________
PLEASE READ RELEASES
* I give permission to the program to transport my child in agency vans and/or staff-operated vehicles to and from
our after-school site on special field trips (separately authorized by parent or guardian).
* I understand and agree that neither the program nor its employees and volunteers are responsible or legally liable
for any personal property losses or for any bodily injuries incurred and suffered by the child on any program
property or in connection with any program activities.
* I give the afterschool staff permission to access school records (grades, attendance, behavior, etc.) about my
child to better serve his/her needs.
* I give the afterschool staff permission to release my child’s student ID # to RISD’s program providers for the
purpose of assessing program effectiveness. Only group data (i.e. information regarding grades, attendance,
behavior, etc. for all the students in the program) will be examined, no data specifically connected to your
student will be identified.
* I understand that the records and information released under this consent will be kept confidential to the extent
permitted by law and will be used for the purpose indicated.
* I understand that if my child is absent from the afterschool program, I will receive a phone call notifying me of
the absence unless I have already given notice that my child is not going to attend the program.
* I understand that if I have any questions about these releases, I can ask my program coordinator.
I AGREE TO THE ABOVE STATEMENTS
(signature)______________________________________________________ (date)______________________
I will allow my child to be photographed and/or videotaped while engaged in program activities and for
those images to be used for publicity and/or recruitment purposes. YES_____ NO______
PLEASE READ AND INITIAL BEHAVIOR MANAGEMENT POLICY
Your child is expected to behave appropriately at all times and follow the rules of _____________________.
(name of school
________I understand that if my child does not follow the rules he or she will receive a verbal warning.
_______ I understand that if the misbehavior continues, I will receive a phone call about my child.
_______ I understand that if the problem continues, my child will be dismissed from the program.
_______ I understand that fighting and/or inappropriate sexual behavior will result in immediate dismissal
from the program.
DO YOU HAVE ANY COMMENTS OR SUGGESTIONS? __________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
ALL INFORMATION IS COMPLETELY CONFIDENTIAL
I am the parent or legal guardian of minor named above and have legal authority to execute this consent
and release.
SIGNATURE: ________________________________________________________ DATE: _______________________
THANK YOU! WE LOOK FORWARD TO THIS YEAR!!
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21st Century Afterschool Program - 2020 -2021 REGISTRATION FORM

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Completed 17 September 2020

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