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Afterschool Program Student Registration Form 2023-2024
Student Information
Student Name
*
First Name
Middle Name
Last Name
Student Nickname
Date of Birth
*
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1922
1921
1920
Year
Gender
*
Please Select
Male
Female
Ethnicity/Race
*
American Indian/Alaskan Native
Asian
Black (not of hispanic origin)
Hispanic or Latino
Middle Eastern
Native Hawaiian or other Pacific Islander
White (not of hispanic origin)
Unknown
Other
Who does your child live with? (Check all that apply)
*
Both parents
Mom
Dad
Grandparents
Extended family
Foster parents
Guardian
Other
Siblings/other children in this household (First name, last name, age)
Home Address (Include apartment and building numbers if applicable)
*
Street Address
Apartment #
Building #
City, State
Postal / Zip Code
Afterschool Program Location
*
Please Select
T.A. Brown
J.J. Pickle
J. Houston
Travis Heights
All Saints Presbyterian Church
Grade for 2023-2024
*
Please Select
Prek
K
1st
2nd
3rd
4th
5th
Is your child in Special Education (SPED)?
*
Please Select
Yes
No
Unsure
Transportation Home
*
Please Select
Picked up
Walks home
Please list any allergies your child has to specific foods. (If none, say none.)
*
Please list any medical needs or medications your child requires during afterschool programming hours. (Leave blank if none)
Does your child have physical restrictions or needs that our staff needs to be aware of for afterschool programming?
*
Please Select
Yes
No
Please explain your child's physical restrictions or needs in as much detail as possible.
Will your child have any scheduling conflicts that will affect their program attendance?
*
Please Select
Yes
No
Please explain any scheduling conflicts.
Parents/Guardians and Authorized Pick-Up List (Must be 18 years or older)
List parents/guardians and additional persons, 18 years or older, who are authorized to pick up the student. Checking "Yes" under "Lives With?" indicates that the person listed is a member of the same household. Individuals younger than 18 or not on this list will not be permitted to pick up the student.
Parent/Guardian 1
*
First Name
Last Name
Home/Work/Cell Phone
Email
Primary Language
Lives with?
*
18 years or older?
*
Parent/Guardian 2
First Name
Last Name
Home/Work/Cell Phone
Email
Primary Language
Lives with?
18 years or older?
Pick-up restrictions (Check if legal restrictions are in effect. List person(s) not allowed to see student at site and/or person(s) not allowed to pick up students per legal restrictions.)
*
Restricted Person 1
First Name
Last Name
Restricted Person 2
First Name
Last Name
Who referred you to Side by Side Kids? (First name, last name)
Primary reason for enrolling student in program (Check all that apply)
*
AISD referral
Other Referral
Academic
Behavior/social
Child showed interest
Convenience
Moved from another program
Spiritual
Working parent
Areas of growth to focus on (Check all that apply)
*
Academic
Behavioral/Social
Spiritual
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Afterschool Program Registration Agreements
All parents/guardians must read the Side by Side Kids (SBSK) Parent Information Form. Please see the corresponding agreements and check the appropriate circle for each statement to complete your child's registration.
*
I have received the SBSK Afterschool attendance policy, via the SBSK Parent Information Form, and understand it is my responsibility to read it.
*
I have received the SBSK Afterschool behavioral procedure, via the SBSK Parent Information Form, and understand it is my responsibility to read it.
*
I have received the SBSK Afterschool dismissal procedure, via the SBSK Parent Information Form, and understand it is my responsibility to read it.
I give permission to SBSK to photograph/video my child for SBSK use only.
*
Please Select
Yes, I give permission.
No, I do not give permission.
I authorize Austin Independent School District (A.I.S.D.) to disclose to SBSK for its enrichment program the following information regarding my child: Copy of Report Card, STAAR Scores, Attendance and Behavioral Information.
*
Please Select
Yes, I give permission.
No I do not give permission.
I give consent for my child to participate in the SBSK data collection, through an annual interview about the benefits of attending the SBSK afterschool program.
*
Please Select
Yes, I give permission.
No, I do not give permission.
I would like to make a donation to Side by Side Kids.
*
Please Select
Yes, I would like to make a donation.
No, I do not want to make a donation.
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Parent/Guardian Acknowledgement, Waiver, and Consent
Permission for transportation
Side by Side Kids has my permission to transport my child to and from the program location, including excursions or other planned events. I understand reasonable precautions will be taken to ensure the safety and provision of my child.
Permission for religious instruction
I understand that Side by Side Kids is based upon Christian principles and that my child will be receiving faith-based teaching and instruction from the teachers and volunteers of Side by Side Kids; I hereby consent to the same.
Medical Waiver
In the event that my child requires emergency medical treatment and I cannot be reached, I hereby authorize Side by Side Kids to make arrangements to transport my child to the nearest hospital/emergency medical facility. I give my consent for any and all necessary medical treatments in the event my child requires attention of a physician and understand that I, not Side by Side Kids, will be financially responsible for the costs of such treatments.
Waiver
I understand that Side by Side Kids activities have inherent risks and I hereby assume all risks and hazards incident to my child's participation in all Side by Side Kids activities, including transportation to and from said activities. I further waive, release, and absolve, indemnify, and agree to hold harmless Side by Side Kids, Austin Independent School District (A.I.S.D.), T.A. Brown Elementary School, J.J. Pickle Elementary School, J. Houston Elementary School, Travis Heights Elementary School, Oak Hill Elementary School, All Saints Presbyterian Church, and all Side by Side Kids and A.I.S.D. organizers, volunteers, supervisors , officers, directors, participants, coaches, referees, and their affiliates as well as persons or parents transporting participants to and from such activities, whether located on Side by Side Kids or A.I.S.D. property or elsewhere.
Parent/Guardian Signature
*
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