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Attention Parents:

We have a limited number of

spaces in the Program

therefore it will be a first

come first serve basis.

There will be a wait list. The

spaces will be filled based on

the timestamp of your

FULLY COMPLETED

Panther Club Registration

Packet. Everything Must be

FULLY filled out or you will

lose your spot.

Panther Club Quick Tips and Reminders

Drop Off and Pick Up- No Parent should enter the building. You will need to bring your child to

the door and Sign them in using your Brightwheel Code to the specified door. After each check

in the iPad will be sanitized.

All Students are required to wear a mask each day. Please make sure your mask is labeled.

Please provide a second mask in the event something happens to the first.

Please provide proper adequate attire as we will be outside as much as possible, weather

permitting.

Any and ALL school issued devices needed for online learning need to be labeled with Child's

name so that there is no mix up between devices.

All devices need to be fully

charged as there are not enough outlets for everyone charging

devices.

Any materials (worksheets,textbook, etc.) needed for the day should be labeled before coming

to Panther Club.

activities for the classroom.

Students Must bring a labeled bag to include ALL belongings.

Students will need to bring lunch and snacks for the day. There will be no school provided food

or beverage options. We will also not have access to heat up any items.

Payments and Calendar MUST be made by the 20th of the month for the following month.

2020 Panther Club Registration Checklist

Parents, please use this checklist to ensure that all Panther Club paperwork is completed. Please keep

a copy of all paperwork for your records.

_______Enrollment Contract

______Emergency Contact (3 pages)

______Monthly Calendar

______Brightwheel Enrollment (if you are new to the program and you need a Brightwheel invitation

email please reach out to the Panther Club Coordinator Colleen Flaherty at

cflaherty@pitman.k12.nj.us)

______Add a Picture to Your Brightwheel Account. It should be a singular picture of just the student

whose account it is.

Panther Club Enrollment Contract (one form per c

amper required)

Childs Name: ____________________________ Grade as of September 2020:______

mail: _____________________________________ Phone: _________________________

To reserve your days, please select the days that you would like to enroll for the month. This must

be done by the 20

of the month for the next month, or a $25 Late Fee will be charged to your

Brightwheel Account. ALL payments and communication should be made through the

Brightwheel App.

Panther Club Enrollment Policies:

● Emergency Contact Forms should be filled out entirely, Please leave no blank options.

There should also be ONE form filled out per student attending Panther Club

● Daily rate for Students: AM- $7.00, Extended Day- $15.00, Half Day- $7.00

and PM- $11.00

● Payment is due the 20th of each month. If there is more than one child in your family a

singular payment can be made under one child’s Brightwheel Account.

● You are responsible to pay for all days selected on your calendar. If for any reason your

child will not be attending Panther Club your Site Leader will need to be informed by 8pm

the night before via the Brightwheel App.

● Payment in the amount of $35 will be charged to your account for any payment

that comes back insufficient funds.

● A $25 late fee will be charged to your account if payment and calendar is not received by

the 20th of the prior month.

● The deadline to reserve your Panther Club days each month is the 20

of the prior month.

PARENT/GUARDIAN AGREEMENT: I, the parent/guardian of_______________ have read the

above Panther Club Enrollment Contract which shall become my obligation to Pitman Board of

Education. I fully understand this obligation and the reasons for its implementation. By signing

below, I am indicating that I have read and agreed to abide by all policies listed in the Parent

Handbook and Panther Club Forms .

Parent/Guardian Signature: _______________________________ Date:

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Pitman Panther Club

Pitman School District

420 Hudson Avenue

Pitman, NJ 08071

(856) 589-2145

2020-2021 School Year Emergency Contact Form

Child’s

Name

Grade

Teacher

School

Birth Date

Child’s

Address

Primary Email

Address:

Sibling (include ages) of Above Named Student:

Mother’s

Name:

Father’sName:

Mother’s

Address:

Father’s Address:

Father’s Home

Phone:

Father’s Cell Phone:

Father’s Work

Phone:

Father’s

Email:

Relationship

Mother’s Home

Phone:

Mother’s Cell Phone:

Mother’s Work

Phone:

Mother’s

Email:

Emergency Contact Name (Not Parent)

Emergency Contact Phone:

Cell:

Work:

The

following adults are given permission to pick up my child/children from Panther Club Program:

Name

Address:

Cell Phone:

Name

Address:

Cell Phone:

Name

Address:

Cell Phone:

Please List any person(s) NOT permitted to pick-up your child/children:

Name

Relationship

Name

Relationship

____ Check here if: I DO NOT grant my permission for photographs or videos of my child, or any of his/her work to be

submitted to newspapers or TV stations for publication or posted on the Pitman School District website. OVER

MEDICAL INFORMATION

*Any medical conditions must be disclosed at the time of registration. We

may not be able to accept your child due to state regulations; only a registered

nurse can administer medications. Panther Club does not employ a nurse

outside of normal school hours.

CHECK IF THE STUDENT HAS ANY OF THE FOLLOWING CONDITIONS:

Heart Condition: Restrictions

yes

Seizure Disorder

Asthma: On medication

yes

Diabetes

Adverse Drug Reaction

Severe Allergies (including food or bee

stings)

Hearing Problems:

Ear tubes

aids

Braces

ADHD: On Medication

yes

Vision problems: Glasses

Contacts

Other:

Fractures

year

Please explain any of the above questions if they are checked:

_____________________________________________________________________________________

My child is on the following medication:

________________________________________________________________

Recent surgery, illnesses, or injuries and date(s):

______________________________________________________________________________

_____________________________________________________________________________________

_____________

Family Physician:

___________________________________________________________________________________

Family Dentist:

_____________________________________________________________________________________

Does your child have health insurance? Yes _____ No _____

If yes, name of insurance company:

_____________________________________________________________________

In case of an EMERGENCY and your child has to be taken to the nearest hospital, your preference is:

_______________________. I give my son/daughter permission to receive emergency hospital

treatment, if necessary.

I hereby give permission to release information regarding my child’s health condition(s) to essential

school personnel and those authorized on the emergency card who assume temporary care of my child in

order to best meet the medical and health needs of my child in the school setting.

_______________________________________ ____________________________

Signature of Parent/Guardian Date

Child Lives With: _____Both Parents ____Mother _____Father_____ Other

Please answer all the questions (1-5) below (Use additional paper if necessary)

1. What does your child like to do in his/her free time?

_______________________

______________________________________________

_____

Describe how your child interacts with his/her peers:

_____________________________________________________________________

Have there been any major changes in your family situation in the past year (family move, separation,

divorce, death, new school, birth, etc.) If so, what effect did this have on your child?

____________________________________________________________________________________

4. Is your child or family receiving any special help with emotional concerns or behavior at school or hom

(

Psychiatrist, counselor, social worker, etc.)

If so, please explain. (Use additional sheet if necessary)________________________________________

____________________________________________________________________________________

5. Is there anything else you would like us to know about your child that will aid us in helping him/her have a safe

and

enj

oyable experience? Any specific concerns about your child? (Use additional sheet if necessary)

___________________________________________________________________________________________

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signature

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Log

in information needs to be provided so that we can easily access any of the devices and/or

activities for the class.

hild’s Name:_________________ Grade:__________

School:__________________ Teacher:__________

Website/Device

Username

Password

lease write any information that will help us to assist your child with their school work:

____________________________________________________________________________

____________________________________________________________________

________

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