CROSSROADS AFTER-SCHOOL PROGRAM REGISTRATION FORM

2016-2017

PLEASE PRINT CLEARLY & LEGIBLE

CHILD/FAMILY INFORMATION

Child’s Name Male Female D.O.B. / / Age

Home Address

TownStateZIP

Home Phone ( ) -Cell Phone:

WHAT SCHOOL WILL YOUR CHILD ATTEND:

WHAT GRADE WILL CHILD ENTER IN AUG, 2016:

DO YOU HAVE A CHILD IN ANOTHER CROSSROADS PROGRAM THAT IS A SIBLING TO THIS APPLICATION? PLEASE PROVIDE NAME OF SIBLING:

In case of emergency, which parent/guardian listed should we contact first?

Parent/Guardian Name 1: Relationship to Child:

Address:

TownStateZIP

Home Phone: ()-Cell Phone: ()-

Email Address:Work Phone: ()-

Parent/Guardian Name 2: Relationship to Child:

Address:

TownStateZIP

Home Phone ( )-Cell Phone: ( )-

Email Address:Work Phone: ( )-

A STUDENT MUST BE PICKED UP BY THE PARENT/GUARDIAN EACH NIGHT BEFORE CLOSING TIME OF THE PROGRAM. IF A PARENT/GUARDIAN IS LATE, A LATE FEE IS INCURRED - $1 PER MINUTE. AFTER 3X OF BEING LATE, THE STUDENT WILL BE DISMISSED FROM PROGRAM.

Unless informed otherwise, the Crossroads Program assumes both parents/guardians listed above may pick up the child.

Student Name:

CROSSROADS AFTER-SCHOOL PROGRAM REGISTRATION FORM

2016-2017

EMERGENCY INFORMATION

In case of emergency and the Crossroads Program is unable to reach the parents/guardians listed above, the following individuals have permission to make decisions regarding the care of my child, including permission to pick up my child from the Crossroads After-School in case of emergency or early dismissal from the Crossroads Program.

Name______Relationship to Child

Address:

Home Phone ( ) -Work ( ) -

Cell ( ) -

Name______Relationship to child

Home Phone ( ) -Work ( ) - Cell ( ) -

Address______

CHILD PICK UP AUTHORIZATION

I give permission for my child to be released from the Crossroads After-School Program to the people listed below at any time. I understand that the Crossroads staff requires that these individuals will need to furnish a Photo Identification before releasing my child.

Name____Name______

Address____Address_____

Home Phone ( ) -___Home Phone ( ) -____

Work Phone ( ) -____Work Phone ( ) -_____

Cell Phone: ()-Cell Phone: ()-

Relationship to child:____Relationship to child:______

Special Orders for picking up child (Please enclose legal documents if specified people are named). _____

Student Name:

CROSSROADS AFTER-SCHOOL PROGRAM REGISTRATION FORM

2016-2017

HEALTH INFORMATION - Indicate “Y” where it applies and explain as necessary.

Asthma____Convulsions____Emotional____Hay Fever___

Diabetes____Hearing___Psychological____Poison Ivy____

Special Diet____Vision____Learning Disability____Insect____ (what)

Physical____ADD/ADHD____Medication____(see school nurse)

Restraints____Injury____Food

Other

Please explain details of above “yes” answers

Special health or emotional note

Is this child currently taking prescribed or over-the-counter medication? YesNo Explain

Are you covered by any hospitalization/medical care policy? Yes__ No

Preferred Hospital______

Name of Insurance CompanyPhone ( )

Address Town/City State Zip

Policy Holder’s Name Policy Holder’s D.O.B. / /

Policy Number

Name of Physician Phone ( ) -

Name of Dentist Phone ( ) -

Special Services received through school or other agency:

PARENT/GUARDIAN AGREEMENT

I understand:

  1. Student safety is important to the Crossroads After-School Program. If you or your student notice something that is concerning or unsafe, we ask that you immediately notify the Site Coordinator. If an injury does occur and the Site Coordinator was not made aware, please notify them of the injury the following day. If your child is injured, the Site Coordinator or designee will notify you.
  2. The information on this form is complete and accurate. I have provided the Crossroads After-School Program with all of the necessary information to properly care for my child’s needs.
  3. I must notify the Crossroads After-School staff in writing immediately of any changes to this form.
  4. It is my responsibility to notify the Crossroads After-School Program if my child will be absent or be withdrawn from the program.

I have read the Crossroads Parent Manual and agree to these policies and procedures.

Parent/Guardian SignatureDate

Student Name:

CROSSROADS AFTER-SCHOOL PROGRAM REGISTRATION FORM

2016-2017

PERMISSION TO PHOTOGRAPH STUDENT(S)

I give the Crossroads After-School Program permission to use photographs of my child in promotional materials such as brochures, ads, videos, East Hartford Public Schools website, or newspaper releases. I will not be informed or reimbursed for such photographs.

FIRST-AID

I give permission to the Crossroads After-School Program to administer First Aid in case of injury. In the event my child needs immediate attention and I cannot be contacted I give the Crossroads After-School staff permission to authorize medical treatment for my child.

MY SIGNATURE ACKNOWLEDGES MY UNDERSTANDING OF AND AGREEMENT TO THE ABOVE.

Parent/Guardian SignatureDate

CROSSROADS AFTER-SCHOOL PROGRAM

LATE FEE POLICY/PARENT PICK UP

2016-2017

Policy:

  1. Crossroad Programs runs Monday - Thursday from 3:30 -6:00 pm. and on Friday from 3:30-4:30 p.m. **with the exception of OConnell West that runs from 2:45-5:30 p.m. M-TH and 2:45-4:30 p.m. on Friday.
  2. Parents must arrive prior to scheduled pick up time each day to sign out their children. All children must be picked up at or before the end time of the program.
  3. We ask that if you are running late, to contact the site coordinator at your child’s after-school program to notify immediately.
  4. We expect all families to be on time to the program for pickup.

After the scheduled closing time parents will be charged $1 per minute for every 1 minute a parent/guardian is late in picking up their child from the after-school program.

After 3 late pickups your child will be dismissed from the program.

Operations of Program:

Crossroad Programs operate Monday - Thursday from 3:30 -6:00 pm and on Friday from 3:30-4:30 p.m.

*Exception: OConnell West Crossroads operates M-TH from 2:45-5:30p.m. and Friday from 2:45-4:30 p.m.

Pick up Procedures:

  1. Pick up your child(ren) at the designated area of the school your child attends.
  2. Please show your driver’s license to staff and sign out your child.

Student Absence or Authorized Change in Pick up:

  1. If your child is absent or you need to pick up your child early from school, you must contact the school directly per district policy.
  2. We ask that if your child will leave early and not attend Crossroads, to email the Site Coordinator of this information.
  3. If you or any other authorized adult cannot pick up your child, please contact the site coordinator to let this person know who will be picking up your child and the information will be updated on the authorized pick up list.

Your child(ren) will be picked up each night from Crossroads before the closing time.

I, , agree to the late policy to pick up my

PARENT NAME

child(ren) in the Crossroads After-School Program. I understand that If I am late 3 times, I understand that my child(ren) will be dismissed/removed from the Crossroads After-School Program.

Signature of Parent/GuardianDate