Framingham Public Schools After School Registration 2016-2017

After School: □ 4 Day Option or Select Days (minimum of 3) □Mon □Tues □ Wed □Thurs

Child Name______

Last First Middle

Age______Date of Birth______Grade______

School______Teacher______

Home Room______Bus Number______

Address______Framingham, MA Zip Code______

□Male □Female Height______Weight______Skin Color______

Identify FeaturesHair Color______Eye Color______Birth Marks______

Please include an updated photo of your child for safety and security purposes.

Dietary Restrictions/Food Allergies or Other Special Considerations______

Is your child receiving any financial aid assistance through the Dept. of EEC? □ Yes □ No

Parent/Guardian (1) ______

Relationship to Child □Mother□Father□Grandparent

□Other Relative□Foster Family□Other______

Phone______

HomeMobileWork

Home Address______

Street Number, Name & Apt.City & Zip Code

Work/School______Work/School Schedule ______Email______

Parent/Guardian (2) ______

Relationship to Child □Mother□Father□Grandparent

□Other Relative□Foster Family□Other______

Phone______

HomeCellWork

Home Address______

Street Number, Name & Apt.City & Zip Code

Work/School______Hours at Work/School ______Email______

Medical History and Emergency Consent Form

Emergency Contact Information (please provide 3 additional adults not including parent/guardian)

Adult Contact #1

Name______Relationship to child______

Local Address______

StreetCityStateZip

Phone______

HomeWorkCell

Adult Contact #2

Name______Relationship to child______

Local Address______

StreetCityStateZip

Phone______

HomeWorkCell

Adult Contact #3

Name______Relationship to child______

Local Address______

StreetCityStateZip

Phone______

HomeWorkCell

Health and Developmental History

In order to serve your child best, please provide the following information below:

1. Allergies (bee, food, medication)□ yes□ no ______

2. Seizures/Epilepsy□ yes□ no ______

3. Hearing/Vision Impairments□ yes□ no ______

4. Chronic Illness (asthma, diabetes)□ yes□ no ______

5. Serious Illness□ yes□ no ______

6. Emotional concerns/disorder□ yes□ no ______

7. Nosebleeds □ yes□ no ______

8. IEP/504 Special Limitations*□ yes□ no ______.

9. **List all Medications□ yes□ no ______

Date of last physical examination______

List of Immunizations and date of last Booster and Tetanus:______

Child’s Physician/Clinic______Address______Phone______

Insurance Information and Policy #______

Transportation Plan

Child Name______

LastFirstMiddle Initial

My child will depart from the program by:

□Bus

□Parent Pick up

□Supervised Walk by ______

□DCF Provided Van

□Other (describe) ______

Authorization for Dismissal from Program

I agree to adhere to the program hours and will pick up my child no later than 5:00pm.

I give permission for my child to be released from the program:

□NO ONE except the Parent/Guardians listed on page 1 of this registration packet

□To the adults listed as Emergency Contacts on page 2 of this registration packet

□Parents/Guardians, Emergency Contacts and the Authorized Adult listed below:

Name______Relationship to child______

Local Address______

StreetCityStateZip

Phone______

HomeWorkCell

ANY OTHER TRANSPORTATION REQUESTS MUST BE STATED IN WRITNG AND MAINTAINED IN THE CHILD’S FILE OR THE ABOVE PLAN MUST BE IMPLEMENTED. PLEASE INFORM PROGRAM STAFF OF ANY CHANGES. VERBAL OR WRITTEN PERMISSION AND PICTURE ID IS REQUIRED FOR ANYONE NOT INCLUDED ON LIST ABOVE.

Allergy Alert!

Please be advised that there may be students that attend the After School Program who have food allergies including ALL NUTS (peanuts and tree nuts) and EGGS. Please do not pack any food from home that may contain nuts or egg.

Please notify program administration about any additional food and/or other allergies to ensure immediate action to keep all campers safe.

Child and Family Individualized Information

In order to provide the best care to your child, please complete the following information.

Is your child receiving any special education services? □ Yes □ No

(IEP, 504, sheltered classroom, occupational therapy, speech therapy, counseling)

______

How would you describe your child’sbehavior on a typical day and what is the best type of discipline (i.e. plays well with others, is withdrawn, is energetic, taking space/timeout is helpful)?

______

Does your child require assistance during transitions such as to the restroom, another activity such as an enrichment club or specialized assistance during homework time? ______

Family Information

Family Size (including yourself and any adults that live in your household) / Total # / Adults # / Children #
Housing (Check one) / Live with Relatives
Own home / Rent Apartment
Housing
Homeless / Shelter
Other
Living Situation (Check all that apply) / 2 Parents
Female Headed
Foster / Grandparent
Male Headed / Teen Parent
Other
Marital Status (Check one) / Divorced Married / Separated / Single
Parent’s Primary Language
Spoken at home
(Check one) / African dialect
Chinese dialect
English / Haitian Creole
Portuguese / Spanish
Other
Employment Status
Parent/Guardian 1 / Employed Full Time
Employed Part Time / Unemployed
Disabled / Attending School
DTA Assistance
Employment Status
Parent/Guardian 2 / Employed Full Time
Employed Part Time / Unemployed
Disabled / Attending School
DTA Assistance

Child Information

Child’s Languages (Check all languages that the child speaks) / African dialect
Chinese dialect
English / French Creole
Portuguese / Spanish
Other
Child’s Ethnicity (Check one) / African American
African
Asian / Cape Verdean
Caribbean
Caucasian / Haitian
Hispanic
Other

Parent/Guardian Contract

Child Name______

LastFirstMiddle Initial

By signing this contract, I agree to terms below:

✓I understand that no program will be provided on non-school days.

✓If my child is on an IEP or 504 plan, I understand that I must authorize After School to access the plan and will schedule a meeting with the After School staff to outline after school accommodations and/or provide the plan with registration.

✓I authorize After School to administer basic first aid and CPR or to seek medical care in the event of an emergency. I understand that the program staff will make every reasonable attempt to contact me, should injury occur.

✓I hereby consent to my child(ren)’s participation in After School activities, including field trips requiring transportation and other off-site activities such as: visits to local parks, libraries, neighborhood walks, etc. daily from 2:30pm (12:00pm on early release days). In giving this consent, I agree that I will not bring suit against program staff or their employers for damage or personal injury incurred by my child while participating in program activities.

✓Photographs and/or video recordings may be taken during the program for use by Framingham Public Schools for materials and/or submitted to the media.

✓I understand that After School reserves the right to dismiss any participant for continual behavior issues consistent with the behavior management policy as outlined in the Family Handbook.

✓I understand it is my responsibility to update all contact information as necessary. I am also responsible to update information and/or renew voucher and provide the After School main office with a copy according to expiration dates. Non-renewal of subsidies will result in full payment of tuition.

✓I consent to program staff sharing program and student updates with school staff.

Cancellation Policy: Withdrawal from the program requires a two week written notice. The cancellation date will be counted from the date the written notification is received. Cancellations should be directed to the Margaret Ayres at the Community Resource Development main office only.

Come to Fuller 21st Century Aviators

and learn something new!

2:25-3:00Arrive at Cafeteria for Attendance and Snack

Homework Support, Games and Activities

3:00-4:30Have fun and learn something new at one of our clubs!

**NOTE: There will only be one club per day this year**

4:30-5:00Get to know your classmates with group activities and time for reflection

Dismissal from cafeteria to buses

Mark your first, second, and third choice for each day below with a 1, 2, or 3 in the box next to the club name. We will try our best to get you into your top choices.

Monday / Tuesday / Wednesday / Thursday
Intro to Graffiti Art / Recycled Art / Anime / Advanced Graffiti Art
Soccer and Basketball / International Club / Soccer and Basketball / Hip Hop
STEM Career Expo / Tools for School with Microsoft / Project Busters / Kodu Coding with Microsoft
Chill Zone / Service Learning / Babysitting Skills / Gardening Club

Student Name: ______

Grade: ______Date of Birth: ______Gender: ______

Parent/Guardian Signature______Date______