BEYOND THE BELL
Afterschool 2015-16
Enrollment Form and Emergency Medical Information
Ridgewood High School and Middle School
[ Please be sure to fill out BOTH SIDES of this form ]
Student Name _____________________________________________________ DOB____/____/_____ Grade_____ Gender______
Address_______________________________________________________________________________________________________________
Parent/Guardian Phone _______________________________ Student Phone(if any) _________________________________
Does the Student have an IEP or a 504 Plan? Y ____ N _____
Are Parents Divorced/Separated? ______ If yes, with whom does the student live?____________________________
Is either parent deceased? ________ If yes, which parent and when? _____________________________________________
If applicable, please list the name of the step-parent _____________________________________________________________
Mother/Guardian information
Name __________________________________________________
Address ________________________________________________
Home Phone __________________________________________
Cell Phone _____________________________________________
Work Phone ___________________________________________
Email Address ________________________________________
Father/Guardian information
Name __________________________________________________
Address ________________________________________________
Home Phone __________________________________________
Cell Phone _____________________________________________
Work Phone ___________________________________________
Email Address ________________________________________
Attendance
Regular attendance in the
afterschool program is strongly
encouraged in order to get the
most benefit. Students who attend
30 or more days are shown to
improve in grades, math and
reading proficiency, homework
completion, class participation,
and behavior issues.
Please encourage your student to
attend as often as possible for
academic work, clubs,
socialization, etc.
Attendance Policy
My student will attend the afterschool program’s homework help on an
as-needed basis, or attend club activities scheduled on different days.
I do not wish to be contacted on days that he/she does not attend.
Parent/Guardian Initials __________
OR
My student will attend the afterschool program every day that it is open,
unless I have excused him/her with a note, phone call, etc.
I wish to be contacted every day that he/she does not attend.
Parent/Guardian Initials __________
LIST THREE PERSONS WHO ARE AUTHORIZED TO PICK UP THE STUDENT
Name and Relationship Home Phone
Cell Phone Work Phone
Name and Relationship Home Phone
Cell Phone Work Phone
Name and Relationship Home Phone
Cell Phone Work Phone
*Please select ONE sign-out option below.
My child MAY sign him/herself out. I understand that Beyond the Bell is not responsible for my child’s safety or whereabouts after leaving the program.
Initials ________________
OR
My child MAY NOT sign him/herself out. Only myself or an adult listed above will sign my child out each day he/she attends.
Initials ________________
DO NOT RELEASE – The following people are not allowed to take my student (court papers required)
Name/Relationship ________________________________________________________________ Papers received on ___________
Name/Relationship ________________________________________________________________ Papers received on ___________
*State Licensing requires that we have the following information for each student
Preferred Physician _________________________________ Preferred Dentist _________________________________________
Does student have any food, medication, or environmental allergies? ______If yes, please list and explain:
EMERGENCY MEDICAL AUTHORIZATION
BEYOND THE BELL HAS PERMISSION to secure
emergency transportation for my student in the event of illness or injury. The emergency transportation service will determine the facility to which my child will be transported
Initials ________________
OR
BEYOND THE BELL DOES NOT HAVE PERMISSION to secure emergency transportation for my student in the event of illness or injury which requires emergency treatment.
Initials ________________
ACKNOWLEDGEMENT OF POLICIES & PROCEDURES
I, the afterschool student, understand that the BEYOND THE BELL afterschool program is an extension of the school day and has the same high expectations for student success and behavior. I also understand that my participation in homework help, clubs, field trips, and other activities are based on my actions and attitude during afterschool and the regular school day. As a Ridgewood student and a BEYOND THE BELL enrollee I agree to respect my peers, afterschool staff, equipment and myself.
Student Signature ___________________________________________________________________ Date _____________________
I, the parent or guardian, give my student permission to attend the BEYOND THE BELL afterschool program. I will read the parent handbook that describes the policies of the program. I will discuss that information with my student, specifically the behavior policy. I am aware of the possibility of receiving a gas voucher based on financial need and will request an application if I wish to receive gas vouchers. I understand that in order for my student to receive the maximum benefit from the program, afterschool staff will receive information from the student’s regular classroom teachers as well as use
information obtained from the Developmental Asset Survey (DAP) that the student will complete upon beginning the program. Y_____ N_____ My student has permission to access the Internet for educational purposes under supervision of the staff.
Y_____ N_____ I give permission for my student’s photograph to be taken during activities and used for program promotion. Y_____ N_____ I give permission for my student to watch suitable PG-13 movies.
BEYOND THE BELL
Afterschool 2015-2016
Enrollment Form and Emergency Medical Information
Grades K - 5
[ Please be sure to fill out BOTH SIDES of this form ]
Student Name _____________________________________________________ DOB____/____/_____ Grade_____ Gender______
Address_______________________________________________________________________________________________________________
Parent/Guardian Phone _______________________________ Student Phone(if any) _________________________________
Does the Student have an IEP or a 504 Plan? Y ____ N _____
Are Parents Divorced/Separated? ______ If yes, with whom does the student live?____________________________
Is either parent deceased? ________ If yes, which parent and when? _____________________________________________
If applicable, please list the name of the step-parent _____________________________________________________________
Mother/Guardian information
Name __________________________________________________
Address ________________________________________________
Home Phone __________________________________________
Cell Phone _____________________________________________
Work Phone ___________________________________________
Email Address ________________________________________
Father/Guardian information
Name __________________________________________________
Address ________________________________________________
Home Phone __________________________________________
Cell Phone _____________________________________________
Work Phone ___________________________________________
Email Address ________________________________________
Attendance
Regular attendance in the
afterschool program is strongly
encouraged in order to get the
most benefit. Students who attend
30 or more days are shown to
improve in grades, math and
reading proficiency, homework
completion, class participation,
and behavior issues.
Please encourage your student to
attend as often as possible for
academic work, clubs,
socialization, etc.
Attendance Policy
Please indicate which day(s) your child will attend Beyond the Bell.
Days Attending: ______ Mon. ______ Tue. ______ Wed. ______ Thurs. ______
Dismissal Procedures
To ensure the safety of your child at dismissal time, we ask that you or a
designated adult (listed on the reverse side of this form) enter the
building to sign your child out. In order to keep your child safe, we will
be requesting photo identification.
No student will be permitted to sign himself/herself out without
written permission of a parent/guardian. I do not hold Ridgewood
Schools or the MVESC liable for my student’s whereabouts once they
have signed out of the Beyond the Bell Program for the day.
LIST THREE INDIVIDUALS WHO ARE AUTHORIZED TO PICK UP THE STUDENT
*
The Ohio Department of Education requires a minimum of three individuals listed below.Name and Relationship Home Phone
Cell Phone Work Phone
Name and Relationship Home Phone
Cell Phone Work Phone
Name and Relationship Home Phone
Cell Phone Work Phone
DO NOT RELEASE – The following people are not allowed to take my student (court papers required)
Name/Relationship ________________________________________________________________ Papers received on ___________
Name/Relationship ________________________________________________________________ Papers received on ___________
*State Licensing requires that we have the following information for each student.
Preferred Physician _________________________________ Preferred Dentist _________________________________________
Does student have any food, medication, or environmental allergies? ______
If yes, please list and explain
:
EMERGENCY MEDICAL AUTHORIZATION
BEYOND THE BELL HAS PERMISSION to secure
emergency transportation for my student in the event of illness or injury. The emergency transportation service will determine the facility to which my child will be transported
Initials ________________
OR
BEYOND THE BELL DOES NOT HAVE PERMISSION to secure emergency transportation for my student in the event of illness or injury which requires emergency treatment.
Initials ________________
ACKNOWLEDGEMENT OF POLICIES & PROCEDURES
__________ Parent Initials: My child has permission to participate in the Beyond the Bell Afterschool Program.
__________ Parent Initials: I have received a Parent Handbook describing the policies & procedures governing the Beyond the Bell Program, funded by the Muskingum Valley Educational Service Center. I am now aware that I may be
eligible to receive gas vouchers if my child participates in Ridgewood’s Free/Reduced Lunch Program. I understand that Gas Voucher Applications are made available by the Site Coordinator upon request.
__________ Parent Initials: I acknowledge that Ridgewood Elementary staff members may share information with the Beyond the Beyond Bell staff regarding my child’s academic needs in order to facilitate personalized & quality reading and math intervention/enrichment activities.
__________ Parent Initials: The Beyond the Bell Program has my permission to photograph or to video tape activities that may include my child for the purpose of promoting the program. (Example: Newsletter, flyers or news articles) __________ Parent Initials: I give permission for my child to use computer equipment and the internet, acknowledging the inherent risk of the internet. Every effort will be made by the Ridgewood Local Schools and the Muskingum Valley
Educational Service Center to protect children from harmful content, including the use of software that blocks offensive content. Unacceptable uses of the computer and/or network by students will result in revoking of access privileges.
__________ Parent Initials: I understand that it is my student’s responsibility to attend the Beyond the Bell Program on the designated days listed on front of this form. I also understand that a parent/guardian, or other individuals listed
above will enter the building and check my student out each day he or she attends. I understand the importance of
being at the school by no later than 5:15 p.m. to take my child home. If an emergency arises and it is impossible to be at the school by 5:15, I will contact the school to notify them that I will be arriving late.
Parent/Guardian