2024-2025 CJ Hicks MORE Before and After School Program Registration Form

Date to start the CJ Hicks Before or After School Program*

First day of school is 07-30-2024

Student Names*

	Last Name	First Name	Grade	Teacher	Age	Gender	Date of Birth
Student 1
Student 2
Student 3
Student 4

Before and/or After Care Selection *

	1 child	2 children	3 children
Before Care-6:00 a.m. to 7:00 a.m. $30 per week per child
After Care-2:05 p.m. to 6:30 p.m. $75 per week per child
Before & After Care $90 per week per child

Student's Address*

Street, City, State and Zip

Street Address Line 2

Mother's Name

First NameLast Name

Mother's Phone Number*

Please enter a valid phone number.

Mother's e-Mail Address*

example@example.com

Father's Name

First NameLast Name

Father's Phone Number

Please enter a valid phone number.

Father's e-Mail Address

example@example.com

The following adults, over the age of 18, have permission to pick up my child(ren) with a picture ID.*

	First and Last Name	Cell Phone	Relationship
Mother
Father
Additional Adult
Additional Adult
Additional Adult
Additional Adult

Persons to contact in the case of emergency when parent or guardian cannot be reached:*

	First and Last Name	Cell Phone	Relationship
Name
Name
Name

After School Payment Options*

	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.
After School On-Line Payments * I am interested in making online payments. I understand there is a fee to make online payments.
Monthly Payments * I would like to pay on the first day of the month to save 5% of the tuition fee.
CAPS * I am eligible to receive CAPS payments. I understand I am responsible for payment until my effective CAPS date with the C.J. Hicks MORE After School Program.

After School Policies Acknowledgement*

	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.
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.
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.
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.

Medical and Educational Information*

	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. * Whenever possible, social distancing of staying at least 3 feet apart will be maintained.
Medical Information * Parents assume liability for injuries and accidents incurred and the cost of treatment during the MORE program.
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.
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.
My child has an IEP - Individual Education Plan.
My child has a 504 Plan.
I authorize the application of nonprescription sunscreen and insect repellent.

Are there any medical concerns the C.J. Hicks MORE Before/After School Program should know about your child? *

	Child's Name	Allergies	Other Medical concerns	Medicine needed	Other information
Child 1
Child 2
Child 3

My child has the following special needs*

	Child's Name	Special educational accommodations	Illness	Allergies	Other health concerns	Medication needed
Child 1
Child 2
Child 3

EMERGENCY MEDICAL AUTHORIZATION*

	Should the child below suffer an injury while in the care of the C.J. Hicks MORE After School Program and the facility is unable to contact me (us) immediately, the facility shall be authorized to secure such medical attention and care for the child as may be necessary. I (We) shall assume responsibility for payment services.	Date of Birth
Student #1
Student #2
Student #3
Student #4

EMERGENCY MEDICAL AUTHORIZATION SIGNATURE*

Should my child (ren) suffer an injury while in the care of the C.J. Hicks MORE After School Program and the facility is unable to contact me (us) immediately, the facility shall be authorized to secure such medical attention and care for my child (ren)as may be necessary. I (We) shall assume responsibility for payment services.

EMERGENCY MEDICAL AUTHORIZATION DATE

Date

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.*

	Please enter information
My child rides bus number
Alternate provisions

For RCPS employees only.

	School	RCPS eMail Addess
I am a RCPS employee

I have read and agree to the C.J. Hicks MORE After School Procedures, Policies and Weekly or Monthly Payment Schedule. Parent's Signature*