After School Program Enrollment Form

Lussier Community Education Center

2024-2025 After-School Program Enrollment Form
Welcome to Lussier Community Education Center, we are pleased to offer our After-School Program for families in need of care for their children beyond the normal school day. Our program is completely free of charge and all meals, activities, and field-trips are included. Our program runs 5 days a week unless there's a MMSD school closing or Holiday. The Center Holidays and Breaks where we will be closed are listed below:

• New Year’s Day (January 1)

• Martin Luther King Jr. Birthday (third Monday in January)

• Memorial Day (last Monday in May)

• Juneteenth (June 19)

• Independence Day (July 4)

• Labor Day (first Monday in September)

• Thanksgiving Day (fourth Thursday in November)

• Friday after Thanksgiving Day

• Winter Break (December 24 – December 31)

Our priorty is to the families of the Wexford Ridge community, and although we transport youth from Muir Elementary to the center and from the center to their homes each evening, we are not able to transport youth home that do not live in the immediate area.

Please complete and submit one form per student being enrolled in the After School Program.
Parent's Name*

First NameLast Name
Parent's Phone Number*

Area CodePhone Number
Parent's Email*
Student's Name*

First NameLast Name
Grade in fall (2024-2025) Students must be going into Kindergarten this fall in order to participate.*

KindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8
Effective date for enrollment in After School Program*

MonthDayYear
Please indicate the month and day that this agreement is to take effect. For example, if you will be using the After School Program from the first day of school, enter 09-09-2024.
Medical Authorization

Medical Consent: I hereby give consent for emergency medical care or treatment, to be used only if I cannot be reached immediately.
Physician and Clinic Information

Physician NameClinic Name
Clinic or Hospital Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's or Clinic's Phone number

Area CodePhone Number
Signature

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Date

MonthDayYear
Date
Are There Any Allergies, Conditions, Dietary Restrictions, Special Considerations or Medical Concerns we should be aware of? *
If there are allergies please describe them and indicate special precautions or care needed:
Parent/Guardian Signature*

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Indicate the day(s) that you anticipate utilizing the After School Program:*

MondayTuesdayWednesdayThursdayFriday
Please indicate your child's default dismissal plan:
My child will remain in the After School Program until being picked up by parent or authorized pick up person on:*

MondayTuesdayWednesdayThursdayFriday
PLEASE FILL OUT ONLY IF CHILD WILL BE LEAVING LCEC NOT BY WAY OF PARENT/GUARDIAN OR AUTHORIZED PICK-UP: My child may leave the Lussier Community Education Center at 5:30 pm to go to:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By way of (check box):

WalkingBike/ScooterCity Bus
Select Days your child will use one of the above options to get home or to an alternative destination.

MondayTuesdayWednesdayThursdayFriday
My child will take the Lussier After-School Van on:

MondayTuesdayWednesdayThursdayFriday
Alternative Drop-Off Address

If you are planning to have your child(ren) dropped off by the Lussier Van each night to a person or address different than your own. Please list that information below:
Alternative Drop-off Name

First NameLast Name
Alternative Drop off Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternative Drop-off Phone Number

Area CodePhone Number
Please specify each person, including the name of parents, who has permission to pick up your child from the After School Program. (Even if the person is listed as an authorized pick-up person they may still be asked to show an ID)
Authorized Person 1:

First NameLast Name
Phone Number 1:

Area CodePhone Number
Authorized Person 2:

First NameLast Name
Phone Number 2:

Area CodePhone Number
Authorized Person 3:

First NameLast Name
Phone Number 3:

Area CodePhone Number
Authorized Person 4:

First NameLast Name
Phone Number 4:

Area CodePhone Number
Parent/Guardian Signature

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Permissions/Agreements (Please initial or write NO on line provided)

Initials   Picture/Photo/Media Release: I give my permission and consent to LCEC and any agency affiliated with the Center to use, print, copy, publish, and reproduce any and all videotapes, audio tapes, photographs, films, digital images, prints reproductions, and likeness of any kind now or hereinafter of my child made by LCEC for advertising, publicity, display, or any purpose whatsoever without fees to be paid to my child. I hereby waive any right I may have to inspect and/or approve the finished product or the advertising copy that may be used in connection therewith or the use to which it may be applied.

Initials Website Release: I give my permission and consent to LCEC and any agency affiliated with the Center to use photos and testimony from my child to be used on the agency's website and social media outlets.

Initials I give permission for my child to participate in field trips and other activities during operating hours. □Transported □Walking

Initials   I am aware that the LCEC Elementary Program Policies Handbook and a summary of the Wisconsin Rules for Licensed Child Care Centers are located on the bulletin board between the Spartan and Garner classrooms and that individual copies are available upon request.

Initials   I understand that accident insurance is not provided by LCEC. I do herby, for myself, heirs, executors and administration, waive and/or release and forever discharge any and all rights and claims for damages that hereafter occur to me or my children arising out of or in any way connected to any participation in LCEC programs.

Initials   I give consent for LCEC staff to work as part of a team with school staff, family, and volunteers, in achieving my child’s after school success.
Absence Agreement

I understand that I am responsible for notifying LCEC of any absences of my child/ren from the after school program by noon the day of the absence. Please call the LCEC front desk at (608)833-4979 to report any absences.
Signature

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Date

MonthDayYear
Date
Statement of Policy
- An Enrollment Form and immunization forms are required for all students participating in this program. Those forms will be linked below and are good for 2 years, so if you have already submitted them in the fall or summer of 2024 then let us know and we will add them to the file for 2024-2025 school year.
- The After School Program ends promptly at 6:00 p.m. After 6:00 p.m., we will attempt to call parents and emergency contacts within the first 30 minutes and if unable to reach anyone, proceed with our required process of calling DCF.
- LCEC has an extensive waitlist and want to accomodate those who are truly in need of a spot. If a child has 3 unexcused absences LCEC has the right to terminate them from our program.
- If your child has a cellphone or any other electronic device, we do ask that they keep those items either locked away in our office or inside of their bookbags until program is over. Our goal is to have them engaged in the after-school projects and activties.
- LCEC is not responsible for any lost or stolen valuables
- If your child has a bike or scooter that they use for transportation, please provide a lock so that we can lock them on our bike rack. We don't have space inside of the building to store their bikes or scooters.
- Middle School and High School Students may participate on a drop-in basis with prior notification from parents.They still must have an enrollment form on file.
- Only persons authorized by the parent or guardian may pick up your child from the After School program. Please notify in the designated space on this form if anyone other than a parent/guardian will pick up your child.
- All students attending the After School Program are required to follow all school and program rules. Behavioral problems will result in parent notification and possible suspension from the program.
- Students with a fever or contagious illness may not participate in the program.
- This program is available for all students, grades K - 12th.
- After School Program runs from September 9th 2024 –May 30, 2025.
I have read and understand the Statement of Policies contained here.*

Agree
Parent/Guardian Signature

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School Age Enrollment Form

Immunization Form

Field Trip Permission Form
Enrollment and Immunizations Forms can be submitted through the links below:
Click to add School-Age Enrollment Form

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Click to add Immunization Form

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Click to add Field Trip Permission Form (Write "All Field Trips" and "All Dates" in the spaces that are asking you to specify the fieldtrips we will attend and the field trip dates") Or write "None" if you do not wish to have your child attend any fieldtrips with our after-school program.

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If your Enrollment packet has been completly filled out, please submit below. Enrollment Status will be on a first come first serve basis and subject to packet being fully completed. The order in which your application is accepted is solely based on this form being fully completed.

Thank you for allowing us to care for your child(ren) we look forward to an amazing school year!
Should be Empty:

Lussier Community Education Center

Medical Authorization

Alternative Drop-Off Address

Absence Agreement

Statement of Policy