After School Enrollment

After School Enrollment

Enrollment paperwork required for students registered in MVS afterschool programming for the 24-25 school year.
Child's Name*

Child's First NameChild's Last Name
Date of Birth*

MonthDayYear
Child's Date of Birth
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(1) Parent/Guardian Name*

First NameLast Name
(1) Relationship to Child*
Please provide your relationship to the child
(1) Email*
example@example.com
(1) Cell Phone Number*
Please enter a valid phone number.
(1) Home Phone Number (if applicable)
Please enter a valid phone number.
(1) Work Phone Number (if applicable)
Please enter a valid phone number.
Home Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(2) Parent/Guardian Name

First NameLast Name
(2) Relationship to Child
Please provide your relationship to the child
(2) Email
example@example.com
(2) Cell Phone Number
Please enter a valid phone number.
(2) Home Phone Number
Please enter a valid phone number.
(2) Work Phone Number
Please enter a valid phone number.
Home Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School Information
Child's Elementary School*
Teacher Name*
Grade*

Kindergarten1st2nd3rd4th
Is your child on an IEP or 504? If yes, please provide us with a copy of your child's plan.*

NoYes, my child has an IEPYes, my child has a 504 planWe are in the evaluation process

Health Information
Child's Pediatrician*
Practice Number*
Please enter a valid phone number.
Practice Name*
Practice Address*
We are required to have up-to-date immunizations on file for each child. Please either provide us with a current summary of your child's immunizations from your child's PCP OR a current Vermont Medical or Religious Immunization Exemption form.

Mail to: Mountain Village School, PO BOX 1432, Stowe, VT 05661

Email to: annex@mountainvillageschool.com

Or upload below
Does your child have any allergies?*
If yes, please list any allergies:
Does your child have any special health conditions?*
If yes, please describe any health conditions:
Does your child take any medications?*
If yes, please list the name, dosage, and administration schedule below:
Are there any specific custody agreements, court orders, or restraining orders pertaining to your child? If yes, please provide a copy to MVS prior to enrollment. *
File Upload

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Health Insurance Information
Carrier
Member ID/Group
Policy Number
Policy Holder

Permission
We will be using Mountain Village School buses daily for pick up from elementary schools. We will also be using Mountain Village School buses for all field trips and scheduled group activities.
I , First Name Last Name give permission for my child, First Name Last Name to ride the Mountain Village School bus for the 2023-2024 school year .
* I understand that the MVS Handbook can be viewed and downloaded at www.mountainvillageschool.com, and I acknowledge that MVS has met its obligation to inform me of its policies and procedures by providing me with the Handbook. I understand that if I have a question regarding a specific area of content in the Handbook, the Director will clarify the area for me.

* I agree to follow all program policies as stated in the Parent Handbook.

* I am aware that certain activities are physically demanding. (If you have concerns regarding your child’s abilities to participate fully, please contact our Afterschool Program Director or Head of School.) I am aware of Mountain Village School's nature based philosopy and amount of time psent outside, in all kinds of weather. I will send my child with the appropriate equipment, such as rain gear, snow gear, sturdy shoes or boots, protective clothing, sunscreen, water bottles, etc. I further understand that equipment, clothing, backpacks, lunchboxes, etc. will experience wear and tear. I understand that both my child and their belongings may come home wet, dirty, muddy, and tired.

* I understand that money, video games, toys, electronic devices, cell phones, trading cards, jewelry, and personal sporting equipment are not to be brought to after school. I understand that the MVS is not responsible for their loss or misplacement.

* I understand that all clothing and personal belongings should be labeled with the child’s name. I understand MVS is not responsible for their loss or misplacement.

* I understand that my child may not be released to anyone without prior written documentation and presentation of a valid photo identification.

* I understand that MVS staff cannot withhold a child from a biological or custodial parent without legal documentation (i.e. court orders, custody agreements, etc.)

* I understand my child will be sent home from MVS if he/she demonstrates inappropriate or aggressive behavior. If behaviors are continuous and uncontrollable or put others at risk my child may be asked to leave. No tuition refunds will be granted if a child is sent home due to behavior.

* I understand that any and all prescription medicine to be administered by MVS staff must be sent in a current prescription bottle. I understand that over the counter medications must be sent in their original container. I understand that MVS staff may only administer medication as it is prescribed on the proper container. I understand that medication will be sent home with the child on a daily basis.

* I understand some specific hazards that may be encountered during the course of a normal day may include: slipping or falling, insect bites, ticks, poison ivy, or bodily injury. I understand and recognize the element of risk inherent in any adventure program, sport, or activity associated with the outdoors. I certify that my child is capable of participation in all of the daily activities and I agree to reinforce the established safety rules and procedures.

* I understand that credits will not be issued for any absences or for program closings due to severe weather or other facility closings where other arrangements have not or could not be made by MVS.

* I understand that MVS is not responsible for and discourages employees from providing paid care and custody for a MVS program participant under the age of 18 outside of an MVS Program (i.e. babysitting).

* The information given in the registration and medical information paperwork is correct and complete to the best of my knowledge and the person herein described has permission to engage in all activities in the program, except as noted (all necessary and important medical information regarding my child has been documented on the medical forms provided in the registration paperwork).

* I understand that there will be a lifeguard on duty when my child is swimming and will be asked to perform a swim test if desired to enter the deep end of the body of water.

* I give my permission for my child to take part in the field trips provided by the MVS after school program. I understand that my child will walk, bike, or be transported by our MVS busses.

* I understand MVS staff may photograph or video record my child for MVS promotional or onsite activity purposes.
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After School Enrollment

School Information

Health Information

Health Insurance Information

Emergency Contacts & Approved Pick Up

Permission