iLearn Academy-21st CCLC After School Program Registration Form

iLearn Academy-21st CCLC After School Program Registration Form
I understand that my child is expected to remain in the program for the full duration of the programming day, and that my child is also expected to attend regularly. Failure to do so may result in dismissal from the program. *
Parent's Initials
I understand that returning the application does not guarantee admission into the program – it is a first come, first serve program. All applications will be reviewed, and families will be notified of acceptance in the program. A waiting list will also be created for students who are not immediately accepted. *
Parent's Initials
iLearn Academy Program Locations (Choose One) *

Bergen ASCS Passaic ASCS Passaic Clifton ASCS Paterson ASCS Hudson ASCS Bronx ASCS
Student Information
Student's Name *

First Name Last Name
Student's Grade *
Emergency Contact Information

Person to call in case of *Emergency* if custodial guardians cannot be reached
Full Name *
Relationship *
Phone Number *
Please enter a valid phone number.
Full Name
Relationship
Phone Number
Please enter a valid phone number.
Person(s) Who Are NOT ALLOWED to Pick Up Student
The individual named below May NOT pick up my child:
Does your child recognize this person and know they cannot leave with them?

Yes No
Section II
PERMISSION FOR STUDENT TO WALK HOME
While it is encouraged that a designated adult picks up children, we realize many parents are not able to pick up their child/children from the program and that some students may live within walking distance. I First Name Last Name (parent/guardian), acknowledge and assume full responsibility of the risks involved in making this decision and hereby give my (son/daughter), First Name Last Name (student’s name) permission to depart the program at Time , on their own.
Late Student Pick Up-Law Enforcement
I also understand that if parents are excessively late picking up their child/children, iLearn Academy may contact local law enforcement for assistance in the situation, for the safety of the child. A fee of $5 will be charged for every 10 minutes past 10 minutes after the regular dismissal time. I must pay this fee in order to keep my child in the program. Parent Initials
Permission for Publicity Release:
I give permission for photographs and videos to be made of my child and to be used solely for publicity and training purposes by the program.
Yes No
Type a label (Parent Initials)
Snack, Allergies and Wellness: The program will provide breakfast and snacks to all participants who are present at the scheduled times. I give permission for my child to participate in food related activities. Please check one of the following:

My child DOES NOT have a food allergy or dietary restriction. My child DOES have a food allergy and dietary restrictions. My child DOES have a food allergy or dietary restriction. He/she may not participate in activities.
If you selected option 2 above, please list what you child may not eat:
Behavior Plan: All regular day school rules are enforced in programming. iLearn Academy implements a behavior plan for students who choose not to abide by program rules. Parents may be contacted for chronic behavior problems. Students may be suspended for a designated period of time, or removed from the program for non-compliant behavior choices. Fighting, bullying, and weapons will or may result in automatic suspension or removal from the program, as determined after due process. Type a label (Parent Initials)
Activities Information Statement: Students may participate in certain contact sports or activities that involve the possibility for injury. I understand that injuries may occur as the result of physical activities. I would like my child to participate in program activities. Type a label (Parent Initials)
Consent and Release Statement: I consent to the above listed student participating in any programs or activities, either on or off campus. I acknowledge that inherent risks may be associated with participation in such activities. I, the custodial guardian, assume such risk on behalf of my child/children and will indemnify and hold harmless iLearn Schools from and against all claims and demands on account of, or in any way from, any accidental occurrence. In the event that my child/children should need further medical treatment while in the program, I give the staff permission to order x-rays, routine tests, or treatments, that may require hospitalization and necessary transportation. I understand that the staff may be unable to contact me at the time when medical treatment is necessary, and therefore grant permission for them to seek and administer such treatment and medication prior to contacting me for further permission. I authorize payment of medical benefits to the health care provider for any services and the release of any medical or over-the-counter medications they deem necessary. I confirm that, to the best of my knowledge, my child/children is/are not allergic to any medications other than listed above. I hereby release iLearn Schools and its officers and representatives of all liabilities that may from this activity. Type a label (Parent Initials)
Contact Information Updates: In the event of an emergency, it is important to have the most updated parent/guardian contact information. I agree to regularly update my child’s contact information with the school and iLearn Academy front office staff. Type a label (Parent Initials)
Signature

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Date

Month Day Year
Date
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iLearn Academy-21st CCLC After School Program Registration Form

Student Information

Emergency Contact Information

Person(s) Who Are NOT ALLOWED to Pick Up Student

Section II