Churchwell and Cockrill PNA Registration

Churchwell & Cockrill PNA - 2024-25 Registration Form

Eligibility: Children currently enrolled at Churchwell and Cockrill Elementary Schools
Fees & Enrollment
- This program is funded in part by a Nita M. Lowey 21st Century Community Learning Centers grant (21st CCLC).
- The program and all activities are provided free of charge to enrollees.
- Since the grant does not fully cover the cost of the program, PNA invites parents and guardians to make a voluntary, tax-deductible contribution to help. (The cost per student not covered by the grant is estimated to be $525 for the 2024-2025 school year.)
- Children are accepted on a first-registered, first-served basis. If the program has reached its capacity, your child will be placed on a Waiting List in the order that enrollment forms are received.
- Children will not be enrolled in the program unless and until all forms have been completed and submitted.
Program Policies
- The program is open according to the official, in-person learning school calendar of Metro Nashville Public Schools, and is closed during breaks/holidays, inclement weather and half-days. If there is not a full day of school, there is no program. Early care is not provided on days in which school opens late.
- Your child will be under the supervision of the PNA staff, from the time he or she arrives at the site, until your child leaves the site, according to your written instructions for departure. Program staff must be notified, in writing, of any changes in the program departure procedures. No child will be released to a person who is not listed on the registration form or to anyone whose behavior may place the child at immediate risk.
- In order to secure their continuing enrollment, children are required to attend the program on a regular basis. It is requested that parents notify the program about long-term absences. Children who do not attend regularly will be at risk of removal from the program.
- Removal or suspension from our program may occur if the following inappropriate behavior is used: stealing; damaging property; using foul language; being disruptive and uncontrollable in the group; harming another student or staff person; inappropriate behavior(s) not solved after repeated attempts; behavior detrimental to the student and/or others. Staff will communicate regularly with families regarding behavior concerns. Every effort will be made by staff to enlist the cooperation of the student and parents to solve problems. Student must be able to function in a learning environment designed with a 15:1 student/teacher ratio. If a student’s behavior is problematic, the parent will be notified and appropriate action will be taken, which may result in removal of the student from the program. Metro Nashville Public School Code Page 2 of 6 of Student Conduct, including zero tolerance violations, will be enforced.
- Parents/guardians are responsible for the repair and/or replacement of program and school materials that are damaged or destroyed by their child.
- All children must be picked up by close of the program day. $1/minute late fee is charged after the end of the program day. A child will be removed from the program if he or she is consistently picked up late.
- Grievances: Parent input concerning the program is important. Feel free to share these comments with the Site Director. If you are unable to resolve questions concerning policies and procedures, you may contact Executive Director Illia Moore at 615.385.7067 (ext. 1).
- Nondiscrimination Notice: It is the policy of PNA not to discriminate on the basis of sex, race, national origin, creed, age, marital status or disability in its programs, activities, or employment policies as required by Title VI and Title VII of the 1964 Civil Rights Acts, Title IX of the 1972 Educational Amendments and Section 504 of the Federal Rehabilitation Act of 1973. Should you have a complaint related to perceived discrimination, contact Executive Director Illia Moore at 615.385.7067 (ext. 1).
I have read and understand the enrollment and program policies*

Clear
Full name*

First nameLast name

Parent / Guardian Information
Full name (primary contact)*

First nameLast name
Full name (secondary contact)

First nameLast name
Cell phone*
Email address*
example@example.com
Home phone
Home address*

Street address

Street address line 2

CityState / Province

Postal / Zip code
Employer
Work phone
Community activities / organizations you are involved in

Child Safety - Release Authorization

For child’s safety, list all persons to whom child may be released,
Person 1
Full name*

First nameLast name
Phone #*
Is there another person to whom your child(ren) may be released?*

YesNo
Person 2
Full name*

First nameLast name
Phone #*
Is there another person to whom your child(ren) may be released?

YesNo
Person 3
Full name*

First nameLast name
Phone #*
Is there another person to whom your child(ren) may be released?

YesNo
Person 4
Full name*

First nameLast name
Phone #*
Is there another person to whom your child(ren) may be released?

YesNo
Person 5
Full name*

First nameLast name
Phone #*

Emergency Information

Do Not Leave Blank
Name of person, other than parent / guardian, authorized to act for the parent in an emergency:
Full name*

First nameLast name
Relationship*
Cell / Home phone*
Employer
Work / Office phone
Name of child’s physician*
Physician's phone #*

Churchwell & Cockrill PNA - 2024-25 Registration Form

Program Policies

Permissions & Statements of Understanding

Child / Student's Information

Second Child / Student's Information

Third Child / Student's Information

Parent / Guardian Information

Child Safety - Release Authorization

Person 1

Person 2

Person 3

Person 4

Person 5

Emergency Information

Medical

Medication 1

Medication 1