AFTERCARE REGISTRATION 2023-2024

AFTERCARE REGISTRATION 2023-2024
Please complete and return this registration form to the Parish Office
Student's Name
Grade Level
Parents (Mr. & Mrs./Mr./Mrs./Ms.)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Email
example@example.com
Father's Name
Cell Phone
Mother's Name
Cell Phone
Student lives with: both parents, mother, father, other:
both, mother, father, other
Other: Please specify name and relationship Name Relationship
Are you registered in SS. Cosmas and Damian Parish?

YesNo
EMERGENCY CONTACT IN CASE PARENT CANNOT BE REACHED Contact Name
Phone
Relationship to Student
2nd Contact
Phone
Relationship to Student
Tuition for 2023-2024

*NOTE: SS. Cosmas and Damian After School Care will be available only on days the Twinsburg Schools are in session.
- Registration fee of $25, due upon registration (one per family)
  - Registration fee waived if registered by 5/31/23
- 3 Days per week - $200 per month or $1800 per year
- 5 Days per week - $300 per month or $2700 per year
Indicate Days Per Week

MondayTuesdayWednesdayThursdayFriday
Program includes daily snack, homework assistance, recreation, weekly Mass, prayers, access to books, crafts, videos, etc. The following additional programs are available at no cost. Please check if your child would like to participate:

Altar Server (grades 4 and up)Children's Choir
The following programs may become available, for an additional cost. Please check if you would have an interest in these being provided.

Math tutoringReading tutoringArt lessonsUkulele lessonsOther
EMERGENCY MEDICAL AUTHORIZATION

Student Information
Student Name

First NameLast Name
Grade
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become illor injured while in attendance in Faith Formation, Sacramental Preparation, "Anchor" Youth Group, Catholic After School Care or other parish events, when parents or guardians cannot be reached.

RESIDENTIAL PARENT OR GUARDIAN:
Mother's Name

First NameLast Name
Daytime Phone
Cell Phone
Father's Name

First NameLast Name
Daytime Phone
Cell Phone
Please enter a valid phone number.
Other's Name

First NameLast Name
Relationship to child
Daytime Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
NAME OF RELATIVE OR CHILDCARE PROVIDER: (In the event a parent or guardian cannot be reached, permission is given to the following people to be contacted or to pick up my child)
Name 1

First NameLast Name
Relationship to child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Phone
Please enter a valid phone number.
Name 2

First NameLast Name
Relationship to child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Phone
Please enter a valid phone number.
PART I OR II MUST BE COMPLETED
PART I: TO GRANT CONSENT

I hereby give consent for the following preferred medical providers and local hospital to be called:
Physician Name
Phone Number
Please enter a valid phone number.
Dentist
Phone
Medical Specialist
Phone
Local Hospital
Phone
Emergency Room
Phone
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctors, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

Facts concerning my child's medical history to which a physician hsould be alerted:
ALLERGIES
CURRENT MEDICATIONS
OTHER MEDICAL CONDITIONS
Date

MonthDayYear
Date
Signature of Parent/Guardian: Address:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature of Parent/Guardian

Clear
PART II: REFUSAL OF CONSENT
I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action:
Date

MonthDayYear
Date
Signature of Parent/Guardian: Address:
Signature of Parent/Guardian

Clear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Information

Please include information for each CHILD of your household as of the 2023-2024 academic school year.
Child 1

First NameLast Name
"Goes By" Name
Date of Birth

MonthDayYear
Date
Grade 2023-24
Email Address
example@example.com
Please indicate if this child has any particular learning needs
Child 2

First NameLast Name
"Goes By" Name
Date of Birth

MonthDayYear
Date
Grade 2023-24
Email
example@example.com
Please indicate if this child has any particular learning needs
Child 3

First NameLast Name
"Goes By" Name
Date of Birth

MonthDayYear
Date
Grade 2023-24
Email
example@example.com
Please indicate if this child has any particular learning needs
Child 4

First NameLast Name
"Goes By" Name
Date of Birth

MonthDayYear
Date
Grade 2023-24
Email
example@example.com
Please indicate if this child has any particular learning needs
Child 5

First NameLast Name
"Goes By" Name
Date of Birth

MonthDayYear
Date
Grade 2023-24
Email
example@example.com
Please indicate if this child has any particular learning needs
Child 6

First NameLast Name
"Goes By" Name
Date of Birth

MonthDayYear
Date
Grade 2023-24
Email
example@example.com
Please indicate if this child has any particular learning needs
Parent Screen Time Form
Screen time exposure and limitations is something that varies family to family. In an effort to help keep screen time consistent for your child(ren) between school, home, and after care, please fill out the following form so we can best assess the amount of screen time for your child. The staff will take this information into consideration in small group and large group environments, and will do their best to adhere to your time.

Please consider the following as you are filling out this form:
- We will have homework time allotted in the program and we recognize that most homework will need to be completed on the students' devices
- Students will have some free time/free choice each day
- Under any circumstances we will not allow games that are not conducive to a Christian environment
- We will incorporate movies and/or short shows into the weekly schedule
- It can be easy to swap between 2 different apps or tabs while on a device, we will do our best to monitor all screens
I would like my child to use their school provided and personal devices for homework use only
Please type yes or no
I would like my child to spend the following amount of time o educational games provided by the school sites (id. Clever, IXL, Class Dojo, ABC Ya, etc.)
Hours/minutes
I would like my child to spend the following amount of time on their personal device for recreational use and entertainment
Hours/minutes
Flocknote Contact

Flocknote is an efficient way to contact parents in the event of a school closing, notification of an important announcement, and monthly updates. You will receive on average 2 emails per month, and a text for day-of notifications (ie. school closures). Please enter a regularly checked phone number and email.
If your family is in need of tuition assistance, contact (Mrs.) Kathleen Yates, Director of After School Care Program. All conversations and requests will be kept confidential.

Please consult the After School Care Family Handbook for additional information (coming soon after registration). If you have questions about any of these learning experiences or the After School Care program itself you may contact Kathleen Yates, Director of the After School Program at (330) 425-8141 X 101
Registration fee of $25.00 is waived if registered by 5-31. No payment is necessary at this time.

First payment for the program will be due in August. Information will follow closer to the date.

Thank you for registering your child(ren)!! We are looking forward to meeting them soon.
Registration fees may be paid via cash, check, or credit card. Cash or checks can be dropped off at the Parish Office:

10439 Ravenna Rd.
Twinsburg, OH 44087

Checks should be made out to Ss. Cosmas and Damian, noting Aftercare in the memo line.

If you are paying online via Pay Pal, please check the box under "My Products" and enter the quantity 1 to pay the amount.
If registering before 5/31, therefore waiving the registration fee, or if paying the registration fee by cash or check, please skip the PayPal Checkout and click 'Submit' below.
My Products
prevnext( X )
Aftercare Registration Fee 2023-2024Waived if registered by 5/31/23. $2.50 added as online processing fee
$27.50 Quantity

Total

$0.00
loading smart payment buttons...

The payment is ready! It will be completed once you submit the form.
Should be Empty:

AFTERCARE REGISTRATION 2023-2024

Tuition for 2023-2024

EMERGENCY MEDICAL AUTHORIZATION

PART I: TO GRANT CONSENT

PART II: REFUSAL OF CONSENT

Child Information

Parent Screen Time Form

Flocknote Contact