After-School Plus (A+) Program
Registration Form
Activities: A variety of scheduled activities
Children usually begin the afternoon with free play time
and a snack period (children bring their own snacks
from home). This period is followed by other activities
including homework time, enrichment and physical tness.
Site Coordinators will have the exibility to adapt scheduled
activities to meet the conditions at your child’s school.
Eligibility: K-6 public elementary school latchkey
children
Your child is considered latchkey if he/she is living with
you and during the hours of A+ operations you are
employed, attending school, engaged in a job training
program, or working as an employee of the A+ program.
A parent/legal guardian who is “self-employed” must
verify their status by: a) Submitting a copy of their general
excise tax license; and b) submitting a copy of one of the
following: 1) income tax return for the past year including
Schedule C; or 2) printed business checking account.
Starting Date: Child’s rst full day of school
Starting date for your child is usually the rst full day of school.
However, the starting date of the A+ Program at your
child’s elementary school may depend on the after-school
enrollment of at least 20 children and the ability to recruit
necessary staff.
The After-School Plus (A+) Program, the rst
program of its kind in the nation, provides statewide
after-school services for public elementary students
at affordable rates. The program addresses the “latch-
key” child problem by providing a high quality after-school
program to children of working parents/legal guardians
or children whose parent/legal guardian is engaged in
job training or attending school during the hours of A+
operations. If your child qualies and you want to enroll
him/her, please complete both sides of this registration form
and return it to your child’s school.
Fee: Due Monthly
The monthly fee covers regular program activities. The
fee will be adjusted for those who qualify if acceptable
supporting documentation about their income or DHS
728 Form is submitted.
Hours: After school - 5:30 p.m.
The program hours are from after school to 5:30 p.m. on
regular school days. The program will not operate
during school vacations, state holidays, weekends, Teacher
Institute Day, Teachers’ work day and school half days.
Supervision: Staff to Student Ratio of 1:20
At each school, the staff will consist of a Site Coordinator
and a group leader team supported by aides to maintain
a
staff to student ratio of 1:20. Staff recruitment may limit the
number of students that a school can serve.
I would like to apply for subsidized monthly tuition. I give my permission to the Hawaii State Department of
Education (HIDOE) and its contracted private providers to use information in HIDOE les or les from
other state agencies to verify my child’s eligibility for subsidized monthly A+ fees.
I have attached the required supporting documentation. (Refer to List of Acceptable Income
Documentation for the After-School Plus (A+) Program on the last page of the A+ Parent Handbook
or check with your school’s A+ Site Coordinator.)
I certify that I am eligible for the A+ Program because I am working, job training, and/or attending school during the
hours of A+ operations. I further certify that the information I have provided on both sides of this application form is cor-
rect and I hereby authorize the HIDOE and its contracted private providers to contact the appropriate parties to verify
this information. I understand that changes on this registration form must be given to the A+ Site Coordinator in
writing by the parent/legal guardian. Registration in the A+ Program is pending completion of this application
and approval of the Site Coordinator.
Parent/Legal Guardian Date Parent/Legal Guardian Date
Parent/Legal Guardian’s Name (please type or print) Parent/Legal Guardian’s Name (please type or print)
Marital status (circle one): Single Married Divorced Marital status (circle one): Single Married Divorced
Separated Widowed Separated Widowed
Please check as appropriate: working Please check as appropriate: working
job training attending school job training attending school
Work/school schedule (Please circle am and/or pm): Work/school schedule (Please circle am and/or pm):
Mon. am/pm to am/pm Mon. am/pm to am/pm
Tues. am/pm to am/pm Tues. am/pm to am/pm
Wed. am/pm to am/pm Wed. am/pm to am/pm
Thurs. am/pm to am/pm Thurs. am/pm to am/pm
Fri. am/pm to am/pm Fri. am/pm to am/pm
q
Check this box if you work rotating shifts or your
q
Check this box if you work rotating shifts or your
work hours vary. Submit a sample schedule to work hours vary. Submit a sample schedule to
Site Coordinator. Site Coordinator.