2022-23 Rockdale Bridges Afterschool Program Application

ROCKDALE BRIDGES AFTERSCHOOL PROGRAM

2022 - 2023 SCHOOL YEAR
WHICH SITE DOES YOUR CHILD ATTEND? *
STUDENT NAME: *

First Name Last Name
STUDENT BIRTH DATE: *

Month Day Year
AGE OF STUDENT: *
STUDENT GTID NUMBER (STATE ID #): *
This STATE ID # is located on the "student summary" page in Infinite Campus)
STUDENT ID NUMBER: *
This RCPS STUDENT ID # is located on the "student summary" page in Infinite Campus)
STUDENT GENDER: *
ETHNICITY: *
PRIMARY LANGUAGE: *
IF OTHER, ENTER HERE:
GRADE LEVEL 22-23: *
NAME OF HOMEROOM TEACHER: *
STUDENT'S SPECIAL EDUCATION STATUS *

Yes, Special Education No, Not Special Education
STUDENT LIVES WITH: *
PARENT/GUARDIAN'S NAME #1: *

First Name Last Name
PARENT/GUARDIAN'S NAME #2

First Name Last Name
HOME ADDRESS: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PARENT/GUARDIAN CELL NUMBER #1: *
EMAIL: *
example@example.com
PARENT/GUARDIAN CELL NUMBER #2:
EMAIL:
example@example.com
SIBLINGS, IF ANY (LIST NAME, GRADE AND SCHOOL): *
Type NONE if there aren't any
MODE OF TRANSPORTATION HOME: *

Bus Car Walker
IN THE EVENT OF AN EMERGENCY HOW WILL YOUR CHILD GET HOME? (I.E. INCLEMENT WEATHER, SUDDEN SCHOOL CLOSURE, ILLNESS) *
EMERGENCY CONTACT: NAME OF PERSON(S) ALLOWED TO PICK UP YOUR CHILD.(PERSON MUST SHOW A PICTURE I.D. TO PICK UP YOUR STUDENT) *

First and Last Name Relationship Phone Number
First and Last Name Relationship Phone Number
IS YOUR CHILD UNDER MEDICAL CARE OR TAKING ANY MEDICATIONS? *

Yes, my child takes medication(s) No, my child does not take medication(s)
IF YES, PLEASE LIST DETAILED MEDICAL NEEDS OF THE STUDENT. *
Type NONE if there aren't any
DOES YOUR CHILD HAVE ANY ALLERGIES, SPECIAL NEEDS, OR DISABILITIES? IF SO, PLEASE LIST BELOW. *
Type NONE if there aren't any
DOES ROCKDALE BRIDGES PROGRAM HAVE PERMISSION TO USE PHOTOS OF YOUR CHILD IN EDUCATIONAL OR PROMOTIONAL MATERIALS? *

Yes, Rockdale Bridges has permission to take photos of my child No, Rockdale Bridges does not have permission to take photos of my child
PLEASE READ EACH ITEM CAREFULLY AND INITIAL EACH TO SHOW UNDERSTANDING
CAR RIDERS ONLY - I UNDERSTAND THAT I AM EXPECTED TO PICK UP MY CHILD
EACH DAY AT (6:00PM PEEK'S) (6:15PM MEMORIAL) (6:15PM SALEM)   Signature*

I UNDERSTAND THAT MY CHILD MAY BE DISMISSED FROM THE AFTERSCHOOL PROGRAM
IF THEY HAVE MORE THAN ONE UNEXCUSED ABSENCE DURING THE PROGRAM.   Signature*

I UNDERSTAND THAT I MAY BE CALLED TO PICK UP MY CHILD IF HE/SHE IS
DISMISSED FROM CLASS FOR INAPPROPRIATE BEHAVIOR.   Signature*

I UNDERSTAND THAT MY CHILD MAY BE DISMISSED FROM THE AFTERSCHOOL PROGRAM
IF THEY RECEIVE MORE THAN ONE DISCIPLINE REFERRAL DURING THE SCHOOL YEAR.   Signature*

I UNDERSTAND THAT MY CHILD WILL BE DISMISSED FROM THE AFTERSCHOOL PROGRAM
IF THEY HAVE MORE THAN ONE UNEXCUSED ABSENCE DURING THE PROGRAM.    Signature
I UNDERSTAND THAT ROCKDALE BRIDGES PROGRAM IS A FREE AFTERSCHOOL PROGRAM FUNDED BY GEORGIA DEPARTMENT OF EDUCATION. BY SIGNING YOUR NAME AND THE DATE, I GIVE PERMISSION FOR ROCKDALE BRIDGES STAFF TO REVIEW MY CHILD'S ACADEMIC FILE FOR PURPOSES OF ANALYZING EFFECTIVENESS AND REPORTING TO FUNDING SOURCES. *

Clear
Should be Empty:

ROCKDALE BRIDGES AFTERSCHOOL PROGRAM

PLEASE READ EACH ITEM CAREFULLY AND INITIAL EACH TO SHOW UNDERSTANDING