2023-2024 CJ Hicks MORE Before and After School Program Registration Form
Student Names
*
Rows
Last Name
First Name
Grade
Teacher
Age
Gender
Student 1
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
Female
Male
Student 2
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
Female
Male
Student 3
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
Female
Male
Student 4
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
Female
Male
Date to start the CJ Hicks Before or After School Program
*
-
Month
-
Day
Year
First day of school is 8-1-2023
Before and After Care Selection
*
Rows
1 child
2 children
3 children
Before Care-6:00 a.m. to 7:00 a.m. $30 per week per child
Yes
No
Yes
No
Yes
No
After Care-2:05 p.m. to 6:30 p.m. $75 per week per child
Yes
No
Yes
No
Yes
No
Before & After Care $90 per week per child
Yes
No
Yes
No
Yes
No
Student's Address
*
Street, City, State and Zip
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent's e-Mail
*
example@example.com
The following adults, over the age of 18, have permission to pick up my child(ren) with a picture ID.
*
Rows
First and Last Name
Cell Phone
Relationship
Mother
Father
Additional Adult
Additional Adult
Additional Adult
Additional Adult
After School Payment Options
*
Rows
Please select
After School Tuition
*
Tuition must be paid on or before the first day of attendance for each week, otherwise, a $10 late fee will be charged.
* Credit is not given for days absent. Tuition will be prorated if there is a school holiday. COVID related absence will be handled on an individual basis.
* A late fee of $1.00 per minute is charged for every minute your child is picked up after 6:30 p.m. Three late pickups will result in removal from the program.
*
RCPS charges $35 for returned checks.
Yes
No
After School On-Line Payments
* I am interested in making online payments. I understand there is a fee to make online payments.
Yes
No
Monthly Payments
* I would like to pay on the first day of the month to save 5% of the tuition fee.
Yes
No
CAPS
* I am eligible to receive CAPS payments. I understand I am responsible for payment until my effective CAPS date.
Yes
No
After School Policies Acknowledgement
*
Rows
Please select
Attendance
Before and after school will not be held when school is not in session for students. This includes but is not limited to early release days, independent learning days, school holidays, inclement weather days or other school closing emergencies.
Yes
No
Homework
* Homework time is provided. A final check of homework will be done by the parent.
* Time is provided for students to do homework from 3:00 p.m. to 4:00 p.m. If the student attends an additional after school club or tutorial, homework assistance may not be provided.
*
There are some activities in which classroom teachers prefer parents to do with their children such as reading to them and student projects.
Yes
No
Pick-Up Information
* A picture id is required to pick up all students.
* If anyone
other than names listed above is picking up your child, we must have a signed note authorizing the pickup from the parent or guardian and the pick-up person must have a picture id.
* The pick-up person must be an adult who is at least 18 years of age.
Yes
No
Personal devices
* Per RCPS policies and procedures, I understand my child may not use their personal device such as a phone, tablet or computer while in after school.
Yes
No
Medical and Educational Information
*
Rows
Please select
Students experiencing Covid-19 or a contagious illness
* Notification of parents in the event their child becomes ill will while in our care will be notified.
* Parents of students who come into contact with a reportable contagious illness will be notified.
* Students experiencing illness or fever are asked to stay home.
*
A mask is optional at this time.
* W
henever possible, social distancing of staying at least 3 feet apart will be maintained.
Yes
No
Medical Information
*
Parents assume liability for injuries and accidents incurred and the cost of treatment during the MORE program.
Yes
No
Medicine Authorization
*
In non-emergency health situations, I authorize the administration of children's fever-reducing/pain killer medication (i.e. Tylenol, Advil, or a generic medication) according to the manufacturer's instructions.
Yes
No
Emergency Medical Attention Authorization
*
In the event of serious illness or injury, I authorize the school to telephone Emergency Medical Services (911) for the immediate transportation to the nearest hospital. I, the parent/legal guardian, authorize the transport and treatment by the hospital emergency staff for my child.
Yes
No
My child has an IEP - Individual Education Plan.
Yes
No
My child has a 504 Plan.
Yes
No
I authorize the application of nonprescription sunscreen and insect repellent.
Yes
No
Are there any medical concerns the C.J. Hicks MORE Before/After School Program should know about your child?
*
Rows
Child's Name
Allergies
Other Medical concerns
Medicine needed
Other information
Child 1
Child 2
Child 3
If school closes due to inclement weather or other emergency, the MORE program will not be in operation. If this occurs, the parent will be notified.
*
Rows
Please enter information
My child rides bus number
Alternate provisions
For RCPS employees only.
Rows
School
RCPS eMail Addess
I am a RCPS employee
Parent's Signature
*
Submit
Should be Empty: