25-26 Springs Valley Afterschool Enrollment Form

1
Student Information* This field is required.
Student Name
Date of Birth
Please Select
Please Select
K
1
2
3
4
5
6
Grade Level (Aug 2025)
Please Select
Please Select
Male
Female
Gender
Please Select
Please Select
White
Black
Asian
Hispanic
Other
Race
2
Do you have another student to enroll?
YESNO
3
Student Information* This field is required.
Student Name
Date of Birth
Please Select
Please Select
K
1
2
3
4
5
6
Grade Level (Aug 2025)
Please Select
Please Select
Male
Female
Gender
Please Select
Please Select
White
Black
Asian
Hispanic
Other
Race
4
Do you have another student to enroll?
YESNO
5
Student Information* This field is required.
Student Name
Date of Birth
Please Select
Please Select
K
1
2
3
4
5
6
Grade Level (Aug 2025)
Please Select
Please Select
Male
Female
Gender
Please Select
Please Select
White
Black
Asian
Hispanic
Other
Race
6
Do you have another student to enroll?
YESNO
7
Student Information* This field is required.
Student Name
Date of Birth
Please Select
Please Select
K
1
2
3
4
5
6
Grade Level (Aug 2025)
Please Select
Please Select
Male
Female
Gender
Please Select
Please Select
White
Black
Asian
Hispanic
Other
Race
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
Please Select
YES
NO
Is this student(s) in Foster Care
9
Parent Email Address
example@example.com
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.
11
Doctor, Phone, Hospital
Doctor
Phone
Hospital
12
Any medical conditions/allergies the staff should be aware of:
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Symptoms:
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Medication:(Note: Hoosier Uplands staff are not allowed to administer medications of any kind.)
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Medical assistance should be contacted immediately if:
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Comments:
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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
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Consent to Share Information* This field is required.Signing this form permits Springs Valley Elementary School 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, 2026. 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.
YESNO
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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.
Yes, I have signed up
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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 Springs Valley Elementary 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 4:00 P.M.
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I agree with all of the above:
Name
Date
Relationship to Student
22
Hoosier Uplands After School Program Policies and Procedures* This field is required.Participation in the activities of this program is mandatory, and all children must participate in all activities to the best of their ability. Because of academic objectives and evaluation of this program, students are required to attend at least 3 days per week and stay through homework/enrichment time (4:00pm) Failure to do this will result in the student being dropped. Pickup time for student(s) is 5:45. Students MUST be picked up by 5:45. First offense of late pickup is a written warning, second will be suspended time out of program determined by program director and any further late pickups following will terminate student from programming. There are zero excuses or exceptions to this policy. Please add as many people as possible to your pickup list to avoid this. Discipline Policies While present at the 21st Century Community Learning Center Program, children are expected to participate in all scheduled curriculum as well as follow the rules and policy guidelines of their respective school. The Hoosier Uplands staff will enforce the schools’ rules and policies accordingly. If a child is causing any type of harm to himself/herself, others, damaging property, or violating school rules, the Hoosier Uplands staff will take immediate action. In severe cases of misbehavior, additional discipline policies as listed below will be put into effect: 1st Offense: Arrange a conference between the parent and staff. 2nd Offense: Suspension from the program for up to 3 days. 3rd Offense: Suspension from the program for up to 30 school days. 4th Offense: Expulsion from the program the remainder of the school year. Physical and verbal aggression or threats toward another student or a staff member will always be treated as a serious offense and is cause for suspension. We strive to provide a safe environment for all participants and take this objective very seriously. All discipline policies are strictly enforced and apply to parent behavior as well
I understand and agree
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Signature of Parent/Guardian* This field is required.
Clear
Should be Empty: