You can always press Enter⏎ to continue
season-fall
24-25 Mitchell Afterschool Enrollment Form
2024-2025 School Year
18
Questions
START
HIPAA
Compliance
1
Student Information
*
This field is required.
Student Name
Date of Birth
Please Select
K
1
2
3
4
5
6
Please Select
Please Select
K
1
2
3
4
5
6
Grade Level (Aug 2024)
Please Select
Male
Female
Please Select
Please Select
Male
Female
Gender
Please Select
White
Black
Asian
Hispanic
Other
Please Select
Please Select
White
Black
Asian
Hispanic
Other
Race
Previous
Next
Submit
Press
Enter
2
Do you have another student to enroll?
YES
NO
Previous
Next
Submit
Press
Enter
3
Student Information
*
This field is required.
Student Name
Date of Birth
Please Select
K
1
2
3
4
5
6
Please Select
Please Select
K
1
2
3
4
5
6
Grade Level (Aug 2024)
Please Select
Male
Female
Please Select
Please Select
Male
Female
Gender
Please Select
White
Black
Asian
Hispanic
Other
Please Select
Please Select
White
Black
Asian
Hispanic
Other
Race
Previous
Next
Submit
Press
Enter
4
Do you have another student to enroll?
YES
NO
Previous
Next
Submit
Press
Enter
5
Student Information
*
This field is required.
Student Name
Date of Birth
Please Select
K
1
2
3
4
5
6
Please Select
Please Select
K
1
2
3
4
5
6
Grade Level (Aug 2024)
Please Select
Male
Female
Please Select
Please Select
Male
Female
Gender
Please Select
White
Black
Asian
Hispanic
Other
Please Select
Please Select
White
Black
Asian
Hispanic
Other
Race
Previous
Next
Submit
Press
Enter
6
Do you have another student to enroll?
YES
NO
Previous
Next
Submit
Press
Enter
7
Student Information
*
This field is required.
Student Name
Date of Birth
Please Select
K
1
2
3
4
5
6
Please Select
Please Select
K
1
2
3
4
5
6
Grade Level (Aug 2023)
Please Select
Male
Female
Please Select
Please Select
Male
Female
Gender
Please Select
White
Black
Asian
Hispanic
Other
Please Select
Please Select
White
Black
Asian
Hispanic
Other
Race
Previous
Next
Submit
Press
Enter
8
Parent(s) or Guardian with whom the child resides:
*
This field is required.
Name
Address
City, Zip Code
Home phone
Cell Phone (if applicable)
Place of Employment
Work Phone
Please Select
YES
NO
Please Select
Please Select
YES
NO
Is this student(s) in Foster Care
Previous
Next
Submit
Press
Enter
9
Parent Email
example@example.com
Previous
Next
Submit
Press
Enter
10
Emergency Contacts
*
This field is required.
List 2 alternates for us to contact in the event that the parents cannot be notified. A minimum of 1 person other than parent/guardian is required.
Previous
Next
Submit
Press
Enter
11
Doctor, Phone, Hospital
Doctor
Phone
Hospital
Previous
Next
Submit
Press
Enter
12
Any medical conditions/allergies the staff should be aware of:
Previous
Next
Submit
Press
Enter
13
Symptoms:
Previous
Next
Submit
Press
Enter
14
Medication:
(Note: Hoosier Uplands staff are not allowed to administer medications of any kind.)
Previous
Next
Submit
Press
Enter
15
Medical assistance should be contacted immediately if:
Previous
Next
Submit
Press
Enter
16
Comments:
Previous
Next
Submit
Press
Enter
17
Your child
must
be signed out from the Afterschool Program by a guardian or person listed below. Please list below the other persons authorized to pick up your child. The Hoosier Uplands staff must be notified in writing of any changes. The first two people listed will be contacted in the case of an emergency, if parent cannot be reached.
Name of Contact
Relationship to student:
Phone:
Contact 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Contact 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Contact 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Contact 1
Contact 2
Contact 3
Name of Contact
Row 0, Column 0
Relationship to student:
Row 0, Column 1
Phone:
Row 0, Column 2
Name of Contact
Row 1, Column 0
Relationship to student:
Row 1, Column 1
Phone:
Row 1, Column 2
Name of Contact
Row 2, Column 0
Relationship to student:
Row 2, Column 1
Phone:
Row 2, Column 2
1
of 3
Previous
Next
Submit
Press
Enter
18
Transportation
Please Select
YES
NO
Please Select
Please Select
YES
NO
Will Transportation on the bus to your home at 5:00 P.M. be needed? (Transportation is limited and not guaranteed)
Directions to your home:
Previous
Next
Submit
Press
Enter
19
Consent to Share Information
*
This field is required.
Signing this form permits Mitchell Community Schools to share confidential information and work together in providing services for students that are enrolled in the 21st Century Community Learning Centers Program. I authorize the school to exchange information relating to the above named student. This agreement will expire on June 30, 2025. This information will be used to develop educational profiles of your child/children. I understand that personal records are protected by various federal and state laws and cannot be disclosed without this, my written consent, unless otherwise authorized.
YES
NO
Previous
Next
Submit
Press
Enter
20
I will sign up for the Remind Me app to receive announcements and communication from Hoosier Uplands After school, link is provided within the documentation provided
*
This field is required.
I will/have signed up
Previous
Next
Submit
Press
Enter
21
For All Participants
I agree to give Hoosier Uplands permission to photograph my child. These photos may be used in support of the program as needed.
I agree to inform my child/children of the policies of this program and will insist that they abide by them while participating in the program.
I agree to give Hoosier Uplands permission to access and keep copies of my child’s academic records, including report cards, standardized test scores and cumulative records. This permission will extend throughout the school year. These scores will be kept confidential and only be used by Hoosier Uplands and Indiana Department of Education.
Hoosier Uplands is not responsible for lost or stolen items such as mp3 players, cell phones, etc.
I understand that priority will be given to students with academic need, working parents, and free/reduce lunch status; however, any student that is enrolled in Mitchell Community Schools is able to apply for the program.
I agree that students that are accepted in to the program will be required to attend at least 3 days per week and stay until 4:15 P.M.
Previous
Next
Submit
Press
Enter
22
I agree with all of the above:
Name
Date
Relationship to Student
Previous
Next
Submit
Press
Enter
23
Signature of Parent/Guardian
*
This field is required.
Clear
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
23
See All
Go Back
Submit