Club Registration Winter 2022

TLC Program Application
Teton Literacy Center is closely monitoring the COVID-19 situation, guidelines and ordinances. Similar to our Winter 2022 afterschool clubs, we will continue to run our Spring 2022 afterschool clubs at full capacity across all afterschool sites. Further, we plan to run our Summer SOAR program at full capacity as well. However, please recognize that if there is an unexpected spike in COVID-19 cases, our programs are subject to change at any time.

Further, at this time, TLC will continue to require all students, staff and volunteers to wear masks while engaged in TLC programs.

TLC COVID-19 Update: Ongoing Pandemic Response
Teton Literacy Center is closely monitoring the COVID-19 situation, guidelines and ordinances. Similar to our Winter 2022 afterschool clubs, we will continue to run our Spring 2022 afterschool clubs at full capacity across all afterschool sites. Further, we plan to run our Summer SOAR program at full capacity as well. However, please recognize that if there is an unexpected spike in COVID-19 cases, our programs are subject to change at any time.

Further, at this time, TLC will continue to require all students, staff and volunteers to wear masks while engaged in TLC programs.

TLC Spring 2022 Afterschool Clubs: Changes & Important Dates
During Spring 2022, Teton Literacy Center, Teton County School District and Jackson Hole Children's Museum are piloting a new format for our elementary afterschool clubs. The ultimate goal of this new format is to increase the capacity of our afterschool programs in the next year, providing more families access to clubs and growing the number of days students can attend.

In this new club structure, Kinder - 5th grade clubs will be offered two days per week at each site (CES, JES and MMES). With the exception of students from outlying schools, we will not mix students from different schools at any site. Therefore, students will remain at their school for all TLC afterschool clubs. Students from outlying schools are welcome to apply and we will consider them for the CES, JES and MMES sites.

In recognition that pickup at MMES can be a challenge, we are working with TCSD to potentially provide an Activity Bus to 1 - 2 stops in town for MMES students on Wednesdays and/or Thursdays. This is not a guarantee.

Spring afterschool clubs will run from Monday, April 11th – Thursday, June 2nd. We will notify families of their status for spring clubs on Thursday, March 10th (all notifications will be sent via email).

TLC 2022 Summer SOAR Program: Application Process, Commitment Expectations & Important Dates
Our Summer SOAR Program will run from Monday, June 20th - Thursday, August 11th. The first four weeks, June 20th - July 14th, will be full days at TLC (9am - 4:30pm). The second four weeks, July 18th - August 11th, SOAR will run for two hours following TCSD's Summer Program.

Families must commit to all eight weeks of programs to be accepted. Due to the increasing waitlist numbers for SOAR, we will be asking families to sign a contract of commitment to all eight weeks of programming. Failure to attend 87% or more days of SOAR programming will result in the reduction of points in future TLC program lotteries.

Further, parents of all accepted students will be required to attend a Mandatory Parent Meeting for their student(s) to participate in SOAR. Parent Meetings will be held the following dates and times. Meeting details and location will be sent after acceptance to program. Families only need to attend one meeting:
- Tuesday, May 17 at 6pm
- Wednesday, May 18 at 12pm
We will notify rising 1st - 5th grade families of their status for SOAR on Thursday, March 17th (all notifications will be sent via email).

Top rising 6th - 8th grade SOAR applicants will be invited to interview with TLC staff in March as a next step in the application process (you will be emailed an invite for your student to participate in this step). Final notifications for rising 6th - 8th grade applicants will be emailed following Spring Break.

Participant Information
Participant Name *

First Name Last Name
Gender *

M-Male F-Female O-Other
Race *
Ethnicity *
Birth Date (MM/DD/YYYY) *

Month Day Year
Grade 2021-2022 *
School Attending 2021-2022 *
TCSD Teacher *

First Name Last Name

Participant Education Information
Does your child have an IEP? *

Yes No Unknown
Is your child in the English Language Program with TCSD? *

Yes No
Is your child in enrolled in free or reduce lunch program with TCSD? *

Yes No Unkown
Shared Information Consent
This authorizes Teton Literacy Center and Teton County School District #1 to share written or verbal information regarding my child’s academic performance, diagnosis, history, including medication, progress, psychological and educational testing, medical and legal information, social welfare and rehabilitation, reports and other materials that are relevant to my child's care. I give my permission for the staff of Teton Literacy Center, this 21st CCLC program with services located at Teton Literacy Center, Munger Elementary School, and Jackson Hole Middle School to review my child’s academic and behavior progress reports or their report card in order to document growth and progress in my child during his/her time in this before/after school or summer program. This includes attendance, academic performance, teacher surveys and information about whether my child has an identified exceptionality, an Individual Education Plan or Academic Improvement Plan, and suggestions from my child’s teacher(s) on how my child can best be helped in the program. TLC will send Wyoming Department of Education grade reports from your child’s teacher using WISERID numbers where data will be aggregated at the state level to protect your child’s identification. This data is collected to evaluate the effectiveness of TLC programs.

I understand that my records are protected under the laws regarding confidentiality, and cannot be disclosed without written consent, except in specific situations. This consent is valid throughout my child receiving services at Teton Literacy Center.
Signature *

Clear

Family Information
Mailing Address *

Postal Address

City State / Province (Abbv. WY)

Postal / Zip Code
Physical Address *

Street Address

Street Address Line 2

City State / Province (Abbv. WY)

Postal / Zip Code
E-mail *
example@example.com
Language Spoken at Home *
1st Parent/Guardian Name *

First Name Last Name
Parent/Guardian Employment Status *
Parent/Guardian Work-Company Name
Relationship to Child *
Cell Phone *

Area Code Phone Number
Home Phone *

Area Code Phone Number
Work Phone *

Area Code Phone Number
2nd Parent/Guardian Name

First Name Last Name
2nd Parent/Guardian Employment Status
2nd Parent/Guardian Work-Company Name
Relationship to Child
Cell Phone

Area Code Phone Number
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Sibling Names and Grades

Emergency Contact

Please provide the name of two people not listed on the previous page (parents/guardians will always be contacted first).
Emergency Contact Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship *
Emergency Contact Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship *
Emergency Contact Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship
Emergency Contact Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship
How will your child get picked up from TLC programs?

All students will meet their club instructor in the cafeteria immediately after school.
Transportation from afterschool clubs *

1-Walk/Bike 2-Bus 3-Pickup
Pick Up Consent

The following individuals are authorized to pick up my child at the end of the program (in addition to previously listed parents/guardians):
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship

Policies and Procedures
This Teton Literacy Program is funded through 21st Century Community Learning Centers funding, which is a FREE PROGRAM for students that could benefit from a variety of stimulating personal enrichment activities that promote school success and well-being in a safe environment. Active attendance and engagement are essential to the student and program’s success. I understand that the requirements of the program include the following:
- Failure to maintain attendance standards may result in termination from the program.
- Parents must attend at least (2) family events during the school year in order for youth to maintain active status in the program.
- Youth will maintain a consistent weekly attendance and may not have more than 2 unexcused absences. Parents or student must call to inform staff in advance if they will not be attending that day (307-733-9242).
- Parents/guardians are required to notify the program if a youth will be absent and/or prior to withdrawal from the program.
- Youth will participate in programming activities with an emphasis on reading, writing, science and/or math skills, as provided.
- Youth will complete pre and post assessments as required by the grant funded contract.
- Parents/Guardians will participate in a satisfaction survey process at least once per year.
- Youth will participate in a satisfaction survey process at least once per year.
Appropriate behavior must be maintained. If there are any disruptive students, every effort will be made to work with the parents to resolve the matter. However, TLC may remove the student from the program if any of the following occurs:
- Verbal abuse or physical abuse of another student, tutor, teacher or staff member.
- Disruptive behavior that affects other learners.
- Disregard for the TLC or school premises.
Commitment to Diversity, Equity and Inclusion: Teton Literacy Center is committed to fostering an inclusive educational environment that serves the emotional and physical well-being of all students we serve. Teton Literacy Center seeks to live and promote these values in all aspects of their programming. By signing below, I understand that any instances of prejudice and/or harm against marginalized classes will not be tolerated while in the presence of TLC's care and/or in communication with TLC staff members.

I have read, understand and agree to comply with the requirements of the policies and procedures listed above. I realize that failure to comply with these requirements may result in loss of my funded space within this program. I release the Teton Literacy Center, its staff, Board of Directors and volunteers from any liability.
Signature *

Clear

Student Expectations
Teton Literacy Center after school Enrichment clubs and Summer SOAR Program are free programs for students that promote school success and student wellbeing in a safe environment. In our programs we aim to guide student behavior in a positive way through providing examples, offering clear directions and reasoning, using reflective language, and questioning. To reach our programmatic goals, the following is a list of expectations for our students. Please take the time and talk with your student about the following points and assure they understand the expectations of students while at TLC.
- Student will respect, listen to, and follow the directions of adults in the classroom. They are here to help students learn and have fun!
- Shoes must be worn at all times in TLC programs.
- Personal belongings (cell phone, toys, etc.) need to stay in a closed backpack at all times unless given permission by a TLC staff member or volunteer.
- Student needs to sit at a table while eating snack.
- Student needs to participate in activities to the best of his/her ability.
- Student must follow TLC’s playground protocols.
- Student understands that there can be students from different schools and of different ages in clubs. Student will be kind to them and be willing to make new friends.
- Student will utilize an indoor voice while in the classrooms to be respectful of others working in quiet spaces.
- Student must ask a teacher before leaving the classroom space for any reason.
- Student must respect others’ physical safety and feelings.
- Student understands that consequences will be applied to disruptive or dangerous behaviors. These will vary depending on the severity of the behavior.
I agree that I will discuss these expectations with my student(s) prior to their first day of a new TLC program.
Signature *

Clear

Teton Literacy Center Consent, Release and Liability Wavier
I/we understand that my child’s participation in Teton Literacy Center and Jackson Hole Children’s Museum out of school programs is voluntary and that my child and I/we are free to choose not to participate. I understand that participation in voluntary out of school activities includes risk of injury that may range in severity from minor to disabling to even death. Although serious injuries are not common in supervised school programs, it is impossible to eliminate the risk.

I understand that Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers will not be liable for personal injuries and/or property damage as a result of my child’s participation in such programs or activities.

I/We, on behalf of myself and my minor child, agree to release, hold harmless and indemnify Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers, from any loss, cost, damage and/or expense of any nature, including all attorneys’ fees and costs which I or my child may have resulting, either directly or indirectly, from my child’s participation in afterschool programs or activities.

I/We give permission for our son/daughter to participate in all Teton Literacy Center and Jackson Hole Children’s Museum afterschool activities and do forever indemnify Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers, from any and all actions, all known and unknown personal injuries or property damage of said minor arising out of said activities, and also all claims or right of action for damages which said minor has or hereafter may acquire.

I also have made arrangements to secure timely pick up of my child at the conclusion of each scheduled program. I understand that Parents/guardians are responsible for providing student transportation to and from activities.

I have read, understand and agree to comply with the requirements of the policies and procedures listed above. I realize that failure to comply with these requirements may result in loss of my funded space within this program. I/we accept the risk and responsibility of participation in Teton Literacy Center and Jackson Hole Children’s Museum afterschool programs and we Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers from any liability.
Signature *

Clear
Medical Treatment Consent
In the event of an emergency, I hereby certify that I am the parent/lawful guardian of {name}, and grant to Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers full authority to take whatever action they may consider appropriate under the circumstances involved regarding the health and safety of my child and authorize them to obtain emergency medical or dental services for my child, if necessary, at my expense. I further consent to transportation of the above named child to the nearest or most appropriated medical facility. I authorize the hospital and attending physicians to submit claims to the above named company and hereby assign benefits directly to this company. I understand that I am financially responsible to providers of service for charges not covered by any insurance payments.
Signature *

Clear
Type of Insurance Coverage *
Name of Primary Health Insurance *
Group Number
Policy Number
Allergies *
Does your child have a physical or psychological condition? *
Is your child carrying medication we should know about? *

Spring & Summer 2022 COVID-19 Program Participation Acknowledgement and Disclosure

Please initial each statement below.
I understand that during this COVID-19 Public Health Emergency I will NOT be permitted to enter the facility beyond the designated drop-off and pick-up area. I understand that this procedure change is for the safety of all persons present in the facility and to limit to the extent possible everyone’s risk of exposure. I understand that it is my responsibility to inform any Emergency Contact persons of the information contained herein.
Signature *

Clear
I understand that IF there is an emergency requiring me to enter the facility beyond the designated drop-off and pick-up area I MUST use hand sanitizer before entering, wash hands immediately upon entering, and wear a mask. While in the facility I must practice social distancing and remain 6ft from all other people, except for my own child.
Signature *

Clear
I understand that to enter the facility premises my child must be free from COVID-19 symptoms. If, during the day, any of the following symptoms appear my child will be separated from the rest of the people in the center. I will be contacted, and my child MUST be picked up from the facility within 30 minutes of being notified. I agree to provide 4 emergency contact names and numbers in case I am unavailable.

Symptoms include:

·   Fever of 100 Degrees Fahrenheit or Higher

·   Dry Cough

·   Shortness of Breath

·   Chills

·   Loss of Taste or Smell

·   Sore Throat

·   Muscle Aches

·   Vomiting

·   Diarrhea

While we understand that many of these symptoms can also be related to non-COVID-19 related issues, we must proceed with an abundance of caution during this Public Health Emergency. These symptoms typically appear 2-7 days after being infected so thank you for taking them seriously. Your child will need to be symptom free without any medications for 72 hours before returning to the facility.
Signature *

Clear
I have read and understand all new TLC policies and procedures related to the COVID-19 Public Health crisis including the updated illness policy and exclusion policy.
Signature *

Clear
I understand that I am required to report on my child’s symptoms before coming to programs each morning, and I also understand that my child’s temperature will be taken upon arrival at TLC programs.
Signature *

Clear
I understand that my child will be required to wash their hands using CDC recommended handwashing procedures before entering the center and throughout the day using warm running water and rubbing with soap for at least 20 seconds.
Signature *

Clear
I understand that outside of care, in order to control my child’s exposure in the community, I will comply with any and all state, county or local social distancing orders and will follow any recommendations from the CDC that limits my risk for exposure including wearing a mask in all public areas and remaining 6ft from all other people.
Signature *

Clear
I will immediately notify Teton Literacy Center management if I become aware of any person with whom my child or I have had contact exhibits any of the symptoms listed in Number 3 above, is advised to self-isolate, quarantine, or has tested positive, or is presumed positive for COVID-19.
Signature *

Clear
I understand that if my child has been tested for COVID-19 for any reason, regardless if they are exhibiting symptoms, my child may not return to TLC without proof of a negative test. I will keep my child home from TLC programs if anyone in our household is awaiting COVID-19 test results. My child will only return to programs if those results are negative.
Signature *

Clear
I understand that while present in the facility each day my child will be in contact with children, teachers and other employees who are also at risk of community exposure. I understand that no list of restrictions, guidelines or practices will remove 100% of the risk of exposure to COVID-19 as the virus can be transmitted by persons who are asymptomatic and before some people show signs of infection. I understand that I play a crucial role in keeping everyone in the facility safe and reducing the risk of exposure by following the practices outlined herein.
Signature *

Clear
I understand that if there is a confirmed case of COVID-19 in one of our Teton Literacy programs, the site will be closed immediately and reopened in consultation with the Teton County Department of Health.
Signature *

Clear
I understand that all new information given since the closure due to COVID-19 supersedes all previous policies and procedures outlines in the Parent Handbook or any other TLC correspondence.
Signature *

Clear
I understand that if any medical provider suggests that my child be tested for COVID-19 for any reason, my child may not return to TLC without proof of a negative test result.
Signature *

Clear
I understand that this is a rapidly changing situation and the policies and procedures may change without notice in accordance with any new guidance released from the Health Department, the Department of Family Services, the CDC, or any other regulatory bodies.
Signature *

Clear
I certify that I have read, understand, and agree to comply with the provisions listed herein. I acknowledge that failure to act in accordance with the provisions listed herein, or with any other policy or procedure outlined by Teton Literacy Center will result in disciplinary action up to and including termination of care.
Signature *

Clear

Photography Consent
The Teton Literacy Center may photograph, interview or videotape my children to use for volunteer instruction, marketing purposes and/or program fundraising. Please indicate below whether your child’s writings or photograph may be used for these purposes:

Photographic Release. Participant does hereby grant and convey unto Teton Literacy Center all right, title, and interest in any and all photographic images, video and/or audio recordings made by TLC during the Participant's activities with TLC, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings. I further grant to the Teton Literacy Center and its representatives the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of these images and recordings in any media now known or later developed as well as my/their name for promoting, publicizing or explaining the Teton Literacy Center and its activities and for administrative or educational purposes.
Signature

Clear

Jackson Hole Children's Museum Supplemental Information (Please complete if your students attend JES)

***Note for Jackson Hole Children's Museum (JHCM) afterschool students: all students accepted into JHCM clubs will have to provide immunization records to JHCM. Once accepted, a JHCM staff member will reach out to you with further directions on how to safely submit these records to JHCM. Thank you!
Parent/Guardian Names, Employers, Employer Addresses and Phones
Please answer for each parent/guardian in the household.
Emergency Contact Names, Addresses and Emails.
List any authorized persons who may pick up your child AND their address and phone number.
Emergency Medical Care

In the case of an emergency, JHCM will not transport your child. They will call the parents or dial 911 for emergency transportation. JHCM staff will not administer medication during programs other than Benadryl and Epi-Pen in the case of an emergency. If your child requires medication during the program, the medication must be in the original container with doctor's orders for the medications. This includes Epi-Pens. If anything is administered, parents will be notified.

JHCM cannot guarantee a food allergen-free environment. Please provide sunscreen for your child(ren). If not provided, JHCM staff will apply program sunscreen if necessary for outdoor activity.
Doctor's Name and Phone Number
Dentist's Name and Phone Number
Authorize JHCM to apply sunscreen provided by parent or program.

Yes No

Spring 2022 Afterschool Clubs: Kinder - 5th Grade Students
Again, during Spring 2022, Teton Literacy Center, Teton County School District and Jackson Hole Children's Museum are piloting a new format for our elementary afterschool clubs. The goal of this new format is to ultimately increase the capacity of our afterschool programs in the next year.

In this new club structure, Kinder - 5th grade clubs will be offered two days per week at each site (CES, JES and MMES). With the exception of students from outlying schools, we will not mix students from different schools at any site. Therefore, students will remain at their school for all TLC afterschool clubs. Students from outlying schools are welcome to apply and we will consider them for the CES, JES and MMES sites.

Students at all locations will meet club instructors immediately following school in the school cafeteria. Pickup will be at 5pm at the appropriate elementary school.

Please reach out to Carisa at carisa@tetonliteracy.org with any questions, comments or concerns around this shift.
Class Registration: Jackson Elementary School Students (Pick-up is at 5:00pm at JES)

Mondays, K-5th Grade Students, Natural Disasters Tuesdays, K-5th Grade Students, Heroes and Monsters
Class Registration: Colter Elementary School Students (Pick-up is at 5:00pm at CES)

Mondays, K-5th Grade Students, Natural Disasters Tuesdays, K-5th Grade Students, Heroes and Monsters
Class Registration: Munger Mountain Elementary School Students (Pick-up is at 5:00pm at MMES)

Wednesdays, K-5th Grade Students, Natural Disasters Thursdays, K-5th Grade Students, Heroes and Monsters

Spring 2022 Afterschool Clubs: 6th - 8th Grade Students
Students are expected to meet their TLC educator at Jackson Hole Middle School at 4:00pm. For students who are only participating in the SPARK Program, pickup will be at 5pm at JHMS. For students who are also participating in JHMS's RAD Program, pickup will be at 7:00pm at JHMS.
6th - 8th Grade Students

Mondays - SPARK

SOAR at TLC

Summer Opportunities in Academics and Recreation
SOAR is a free eight-week intensive summer program for students exiting Kindergarten through 7th grade this school year. SOAR consists of four weeks of full-day programming and four weeks of half-day programming, designed to coincide with TCSD's summer program.

Each student enrolled must commit to attending all eight weeks of SOAR.

Dates:

Full Day: June 20th - July 14th (No programs on July 4th)

Elementary & Middle School Students: 9am - 4:30pm

Half Day: July 18th - August 11th

Elementary Students: 3pm - 5pm

Middle School Students: 1pm - 3pm

Please only apply for TLC's SOAR if you can commit to all 8 weeks of programs!
Would you like to apply for the Summer SOAR Program? *

Yes No
If your child has been enrolled in the Summer SOAR program in the past, check all the years they have participated.

2018 2019 2020 2021

Multiple Student Registration
Do you want to apply for another student?

Yes No

Click submit in order to complete the application.

Participant Information
Participant Name *

First Name Last Name
Gender *

M-Male F-Female O-Other
Race *
Ethnicity *
Birth Date (MM/DD/YYYY) *

Month Day Year
Grade 2021-2022 *
School Attending 2021-2022 *
TCSD Teacher *

First Name Last Name
Participant Education Information
Does your child have an IEP? *

Yes No
Is your child in the English Language Program with TCSD? *

Yes No
Shared Information Consent
This authorizes Teton Literacy Center and Teton County School District #1 to share written or verbal information regarding my child’s academic performance, diagnosis, history, including medication, progress, psychological and educational testing, medical and legal information, social welfare and rehabilitation, reports and other materials that are relevant to my child's care. I give my permission for the staff of Teton Literacy Center, this 21st CCLC program with services located at Teton Literacy Center, Munger Elementary School, and Jackson Hole Middle School to review my child’s academic and behavior progress reports or their report card in order to document growth and progress in my child during his/her time in this before/after school or summer program. This includes attendance, academic performance, teacher surveys and information about whether my child has an identified exceptionality, an Individual Education Plan or Academic Improvement Plan, and suggestions from my child’s teacher(s) on how my child can best be helped in the program. TLC will send Wyoming Department of Education grade reports from your child’s teacher using WISERID numbers where data will be aggregated at the state level to protect your child’s identification. This data is collected to evaluate the effectiveness of TLC programs.

I understand that my records are protected under the laws regarding confidentiality, and cannot be disclosed without written consent, except in specific situations. This consent is valid throughout my child receiving services at Teton Literacy Center.
Signature *

Clear
Teton Literacy Center Consent, Release and Liability Wavier
I/we understand that my child’s participation in Teton Literacy Center and Jackson Hole Children’s Museum out of school programs is voluntary and that my child and I/we are free to choose not to participate. I understand that participation in voluntary out of school activities includes risk of injury that may range in severity from minor to disabling to even death. Although serious injuries are not common in supervised school programs, it is impossible to eliminate the risk.

I understand that Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers will not be liable for personal injuries and/or property damage as a result of my child’s participation in such programs or activities.

I/We, on behalf of myself and my minor child, agree to release, hold harmless and indemnify Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers, from any loss, cost, damage and/or expense of any nature, including all attorneys’ fees and costs which I or my child may have resulting, either directly or indirectly, from my child’s participation in afterschool programs or activities.

I/We give permission for our son/daughter to participate in all Teton Literacy Center and Jackson Hole Children’s Museum afterschool activities and do forever indemnify Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers, from any and all actions, all known and unknown personal injuries or property damage of said minor arising out of said activities, and also all claims or right of action for damages which said minor has or hereafter may acquire.

I also have made arrangements to secure timely pick up of my child at the conclusion of each scheduled program. I understand that Parents/guardians are responsible for providing student transportation to and from activities.

I have read, understand and agree to comply with the requirements of the policies and procedures listed above. I realize that failure to comply with these requirements may result in loss of my funded space within this program. I/we accept the risk and responsibility of participation in Teton Literacy Center and Jackson Hole Children’s Museum afterschool programs and we Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers from any liability.
Signature *

Clear
Medical Treatment Consent
In the event of an emergency, I hereby certify that I am the parent/lawful guardian of {participantName}, and grant to Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers full authority to take whatever action they may consider appropriate under the circumstances involved regarding the health and safety of my child and authorize them to obtain emergency medical or dental services for my child, if necessary, at my expense. I further consent to transportation of the above named child to the nearest or most appropriated medical facility. I authorize the hospital and attending physicians to submit claims to the above named company and hereby assign benefits directly to this company. I understand that I am financially responsible to providers of service for charges not covered by any insurance payments.
Signature *

Clear
Type of Insurance Coverage *
Name of Primary Health Insurance
Group Number
Policy Number
Allergies *
Does your child have a physical or psychological condition? *
Is your child carrying medication we should know about? *
Photography Consent
The Teton Literacy Center may photograph, interview or videotape my children to use for volunteer instruction, marketing purposes and/or program fundraising. Please indicate below whether your child’s writings or photograph may be used for these purposes:

Photographic Release. Participant does hereby grant and convey unto Teton Literacy Center all right, title, and interest in any and all photographic images, video and/or audio recordings made by TLC during the Participant's activities with TLC, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings. I further grant to the Teton Literacy Center and its representatives the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of these images and recordings in any media now known or later developed as well as my/their name for promoting, publicizing or explaining the Teton Literacy Center and its activities and for administrative or educational purposes.
Signature

Clear

Spring 2022 Afterschool Clubs: Kinder - 5th Grade Students
Again, during Spring 2022, Teton Literacy Center, Teton County School District and Jackson Hole Children's Museum are piloting a new format for our elementary afterschool clubs. The goal of this new format is to ultimately increase the capacity of our afterschool programs in the next year.

In this new club structure, Kinder - 5th grade clubs will be offered two days per week at each site (CES, JES and MMES). With the exception of students from outlying schools, we will not mix students from different schools at any site. Therefore, students will remain at their school for all TLC afterschool clubs. Students from outlying schools are welcome to apply and we will consider them for the CES, JES and MMES sites.

Students at all locations will meet club instructors immediately following school in the school cafeteria. Pickup will be at 5pm at the appropriate elementary school.

Please reach out to Carisa at carisa@tetonliteracy.org with any questions, comments or concerns around this shift.
Class Registration: Jackson Elementary School Students (Pick-up is at 5:00 pm at JES)

Mondays, K-5th Grade Students, Natural Disasters Tuesdays, K-5th Grade Students, Heroes and Monsters
Class Registration: Colter Elementary School Students (Pick-up is at 5:00 pm at CES)

Mondays, K-5th Grade Students, Natural Disasters Tuesdays, K-5th Grade Students, Heroes and Monsters
Class Registration: Munger Mountain Elementary School Students (Pick-up is at 5:00pm at MMES)

Wednesdays, K-5th Grade Students, Natural Disasters Thursdays, K-5th Grade Students, Heroes and Monsters

Spring 2022 Afterschool Clubs: 6th - 8th Grade Students
Students are expected to meet their TLC educator at Jackson Hole Middle School at 4:00pm. For students who are only participating in the SPARK Program, pickup will be at 5pm at JHMS. For students who are also participating in JHMS's RAD Program, pickup will be at 7:00pm at JHMS.
6th - 8th Grade Students

Mondays - SPARK

SOAR at TLC

Summer Opportunities in Academics and Recreation
SOAR is a free eight-week intensive summer program for students exiting Kindergarten through 7th grade this school year. SOAR consists of four weeks of full-day programming and four weeks of half-day programming, designed to coincide with TCSD's summer program.

Each student enrolled must commit to attending all eight weeks of SOAR.

Dates:

Full Day: June 20th - July 14th (No programs on July 4th)

Elementary & Middle School Students: 9am - 4:30pm

Half Day: July 18th - August 11th

Elementary Students: 3pm - 5pm

Middle School Students: 1pm - 3pm

Please only apply for TLC's SOAR if you can commit to all 8 weeks of programs!
Would you like to apply for the summer SOAR program at TLC? *

Yes No
If your child has been enrolled in the Summer SOAR program in the past, check all the years they have participated.

2018 2019 2020 2021

Multiple Student Registration
Do you want to apply for another student? *

Yes No

Click submit in order to complete the application.

Participant Information
Participant Name *

First Name Last Name
Gender *

M-Male F-Female O-Other
Race *
Ethnicity *
Birth Date (MM/DD/YYYY) *

Month Day Year
Grade 2021-2022 *
School Attending 2021-2022 *
TCSD Teacher *

First Name Last Name

Participant Education Information
Does your child have an IEP? *

Yes No
Is your child in the English Language Program with TCSD? *

Yes No
Shared Information Consent
This authorizes Teton Literacy Center and Teton County School District #1 to share written or verbal information regarding my child’s academic performance, diagnosis, history, including medication, progress, psychological and educational testing, medical and legal information, social welfare and rehabilitation, reports and other materials that are relevant to my child's care. I give my permission for the staff of Teton Literacy Center, this 21st CCLC program with services located at Teton Literacy Center, Munger Elementary School, and Jackson Hole Middle School to review my child’s academic and behavior progress reports or their report card in order to document growth and progress in my child during his/her time in this before/after school or summer program. This includes attendance, academic performance, teacher surveys and information about whether my child has an identified exceptionality, an Individual Education Plan or Academic Improvement Plan, and suggestions from my child’s teacher(s) on how my child can best be helped in the program. TLC will send Wyoming Department of Education grade reports from your child’s teacher using WISERID numbers where data will be aggregated at the state level to protect your child’s identification. This data is collected to evaluate the effectiveness of TLC programs.

I understand that my records are protected under the laws regarding confidentiality, and cannot be disclosed without written consent, except in specific situations. This consent is valid throughout my child receiving services at Teton Literacy Center.
Signature *

Clear

Teton Literacy Center Consent, Release and Liability Wavier
I/we understand that my child’s participation in Teton Literacy Center and Jackson Hole Children’s Museum out of school programs is voluntary and that my child and I/we are free to choose not to participate. I understand that participation in voluntary out of school activities includes risk of injury that may range in severity from minor to disabling to even death. Although serious injuries are not common in supervised school programs, it is impossible to eliminate the risk.

I understand that Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers will not be liable for personal injuries and/or property damage as a result of my child’s participation in such programs or activities.

I/We, on behalf of myself and my minor child, agree to release, hold harmless and indemnify Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers, from any loss, cost, damage and/or expense of any nature, including all attorneys’ fees and costs which I or my child may have resulting, either directly or indirectly, from my child’s participation in afterschool programs or activities.

I/We give permission for our son/daughter to participate in all Teton Literacy Center and Jackson Hole Children’s Museum afterschool activities and do forever indemnify Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers, from any and all actions, all known and unknown personal injuries or property damage of said minor arising out of said activities, and also all claims or right of action for damages which said minor has or hereafter may acquire.

I also have made arrangements to secure timely pick up of my child at the conclusion of each scheduled program. I understand that Parents/guardians are responsible for providing student transportation to and from activities.

I have read, understand and agree to comply with the requirements of the policies and procedures listed above. I realize that failure to comply with these requirements may result in loss of my funded space within this program. I/we accept the risk and responsibility of participation in Teton Literacy Center and Jackson Hole Children’s Museum afterschool programs and we Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers from any liability.
Signature *

Clear
Medical Treatment Consent
In the event of an emergency, I hereby certify that I am the parent/lawful guardian of {participantName148}, and grant to Teton Literacy Center and Jackson Hole Children’s Museum, their employees, Board of Directors and volunteers full authority to take whatever action they may consider appropriate under the circumstances involved regarding the health and safety of my child and authorize them to obtain emergency medical or dental services for my child, if necessary, at my expense. I further consent to transportation of the above named child to the nearest or most appropriated medical facility. I authorize the hospital and attending physicians to submit claims to the above named company and hereby assign benefits directly to this company. I understand that I am financially responsible to providers of service for charges not covered by any insurance payments.
Signature *

Clear
Type of Insurance Coverage *
Name of Primary Health Insurance
Group Number
Policy Number
Allergies *
Does your child have a physical or psychological condition? *
Is your child carrying medication we should know about? *

Photography Consent
The Teton Literacy Center may photograph, interview or videotape my children to use for volunteer instruction, marketing purposes and/or program fundraising. Please indicate below whether your child’s writings or photograph may be used for these purposes:

Photographic Release. Participant does hereby grant and convey unto Teton Literacy Center all right, title, and interest in any and all photographic images, video and/or audio recordings made by TLC during the Participant's activities with TLC, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings. I further grant to the Teton Literacy Center and its representatives the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of these images and recordings in any media now known or later developed as well as my/their name for promoting, publicizing or explaining the Teton Literacy Center and its activities and for administrative or educational purposes.
Signature *

Clear

Spring 2022 Afterschool Clubs: Kinder - 5th Grade Students
Again, during Spring 2022, Teton Literacy Center, Teton County School District and Jackson Hole Children's Museum are piloting a new format for our elementary afterschool clubs. The goal of this new format is to ultimately increase the capacity of our afterschool programs in the next year.

In this new club structure, Kinder - 5th grade clubs will be offered two days per week at each site (CES, JES and MMES). With the exception of students from outlying schools, we will not mix students from different schools at any site. Therefore, students will remain at their school for all TLC afterschool clubs. Students from outlying schools are welcome to apply and we will consider them for the CES, JES and MMES sites.

Students at all locations will meet club instructors immediately following school in the school cafeteria. Pickup will be at 5pm at the appropriate elementary school.

Please reach out to Carisa at carisa@tetonliteracy.org with any questions, comments or concerns around this shift.
Class Registration: Jackson Elementary School Students (Pick-up is at 5:00 pm at JES)

Mondays, K-5th Grade Students, Natural Disasters Tuesdays, K-5th Grade Students, Heroes and Monsters
Class Registration: Colter Elementary School Students (Pick-up is at 5:00 pm at CES)

Mondays, K-5th Grade Students, Natural Disasters Tuesdays, K-5th Grade Students, Heroes and Monsters
Class Registration: Munger Mountain Elementary School Students (Pick-up is at 5:00 pm at MMES)

Wednesdays, K-5th Grade Students, Natural Disasters Thursdays, K-5th Grade Students, Heroes and Monsters

Spring 2022 Afterschool Clubs: 6th - 8th Grade Students
Students are expected to meet their TLC educator at Jackson Hole Middle School at 4:00pm. For students who are only participating in the SPARK Program, pickup will be at 5pm at JHMS. For students who are also participating in JHMS's RAD Program, pickup will be at 7:00pm at JHMS.
6th - 8th Grade Students

Mondays - SPARK

SOAR at TLC

Summer Opportunities in Academics and Recreation
SOAR is a free eight-week intensive summer program for students exiting Kindergarten through 7th grade this school year. SOAR consists of four weeks of full-day programming and four weeks of half-day programming, designed to coincide with TCSD's summer program.

Each student enrolled must commit to attending all eight weeks of SOAR.

Dates:

Full Day: June 20th - July 14th (No programs on July 4th)

Elementary & Middle School Students: 9am - 4:30pm

Half Day: July 18th - August 11th

Elementary Students: 3pm - 5pm

Middle School Students: 1pm - 3pm

Please only apply for TLC's SOAR if you can commit to all 8 weeks of programs!
Would you like to apply for the summer SOAR program? *

Yes No
If your child has been enrolled in the Summer SOAR program in the past, check all the years they have participated.

2018 2019 2020 2021

Click submit in order to complete the application.
Should be Empty:

TLC Program Application

TLC COVID-19 Update: Ongoing Pandemic Response

TLC Spring 2022 Afterschool Clubs: Changes & Important Dates

TLC 2022 Summer SOAR Program: Application Process, Commitment Expectations & Important Dates

Participant Information

Participant Education Information

Shared Information Consent

Family Information

Family Information

Emergency Contact

How will your child get picked up from TLC programs?

Pick Up Consent

Policies and Procedures

Student Expectations

Teton Literacy Center Consent, Release and Liability Wavier

Medical Treatment Consent

Spring & Summer 2022 COVID-19 Program Participation Acknowledgement and Disclosure

Photography Consent

Jackson Hole Children's Museum Supplemental Information (Please complete if your students attend JES)

Spring 2022 Afterschool Clubs: Kinder - 5th Grade Students

Spring 2022 Afterschool Clubs: 6th - 8th Grade Students

SOAR at TLC

Multiple Student Registration

Click submit in order to complete the application.

Participant Information

Participant Education Information

Shared Information Consent

Teton Literacy Center Consent, Release and Liability Wavier

Medical Treatment Consent

Photography Consent

Spring 2022 Afterschool Clubs: Kinder - 5th Grade Students

Spring 2022 Afterschool Clubs: 6th - 8th Grade Students

SOAR at TLC

Multiple Student Registration

Click submit in order to complete the application.

Participant Information

Participant Education Information

Shared Information Consent

Teton Literacy Center Consent, Release and Liability Wavier

Medical Treatment Consent

Photography Consent

Spring 2022 Afterschool Clubs: Kinder - 5th Grade Students

Spring 2022 Afterschool Clubs: 6th - 8th Grade Students

SOAR at TLC

Click submit in order to complete the application.