2025-2026 21st CCLC After School Program Application After School Program

21st CCLC After School Program Application After School Program - Summer and School Year 2025-2026
STUDENT APPLICATION and RELEASE OF INFORMATION FORM

Student/Parent/Guardian: Please provide the following information and return this form to Communities In Schools office. This application does not guarantee enrollment in the program as placement is dependent on available slots. Students may be placed on a waiting list. Thank you for your interest in the program!
Student Information
Student ID*
Student Name*
School*
Grade*
Date of Birth*

MonthDayYear
Date
Parent/Guardian Information
Parent/Guardian Name*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Emergency Contact #1 Name*
Emergency Contact #1 Phone*
Please enter a valid phone number.
Emergency Contact #2 Name
Emergency Contact #2 Phone
Please enter a valid phone number.
List any allergies your student may have*
List any medications your student may be taking*
Program Transporation
My student will: [check all that apply.]*

Walk home from programRide the program provided bus home (Bus stop will be assigned)Be picked-up after the 21st CCLC program
Name of Person Picking Up #1
Relationship to Student
Phone Number
Please enter a valid phone number.
Name of Person Picking Up #2
Relationship to Student
Phone Number
Please enter a valid phone number.
I give permission for my child to participate in Communities In Schools of Eastern Pennsylvania (CIS) programs and services in the school district while he/she is enrolled in his/her current school district or until I notify CIS, in writing,
of my desire to withdraw my student from CIS services.

By signing this Parent/Guardian Consent/Release of Information, I authorize the following:

· I give permission for my student to participate in the program. The services may include but are not limited to supportive guidance/counseling, educational support, tutoring, mentoring, and enrichment activities, and referrals, as needed. Signed releases will be obtained for parent/guardian permission in the event of referral.

· I give permission for routine or emergency medical or dental treatment by any licensed medical practitioner at the closest facility to be provided in the event of illness or accident if I am unable to be reached. I further state that I will not hold CIS, the school district, or any other authorized work site, organization, or agency liable for medical treatment in case of illness, accident or any other emergency situation.

· I acknowledge that this consent is voluntary and may be revoked at any time by informing CIS staff, in writing, except that prior consent will still apply to the extent that agencies have already taken action in reliance of it.

· I understand that as the recipient of supports I or my child can file a complaint if they have a concern about the services they receive from Communities In Schools of Eastern PA, Inc. I will be encouraged to attempt to work out the problem directly with the CIS Staff, but if I cannot do that or if I am unsatisfied with the outcome I may begin the grievance procedure. I understand that Client Grievance Forms are available at all program locations, by calling the CIS office at 484-834-8830.
YesNo
Classroom Dojo: I hereby authorize the 21st CCLC after school program to send messages to the below cellphone number through Classroom Dojo*

YesNo
CONSENT/RELEASE OF INFORMATION

I hereby authorize my student’s school/district and representatives from the organizations listed below to exchange information (such as grades, test scores, attendance, behavior) regarding my student.

· To further my student’s academic, personal and vocational development, I will participate in parent/guardian-team conferences to discuss my child's progress (through either a home visit or a school visit) as needed.

· I hereby give permission for my student to be interviewed by an external evaluator, which may include and is not limited to Educational Enterprises, LLC or Moravian College to evaluate the quality of CIS programs and services.

Communities in Schools now has an electronic platform to engage with your student for supports and assessments. The Communities In Schools Student Portal provides an additional avenue for your child to check-in and set their goals with their CIS Site Coordinator. The CIS Student Portal is helpful for ensuring that students are engaged in the process of reaching their goals and that staff have the tools and information needed to develop meaningful relationships to better address student needs. Using the CIS Student Portal, students can see their goals and CIS support activity, check-in on their progress, and request to speak with their site coordinator. Use of the CIS Student Portal is optional. I give permission for my student access the CIS Student Portal.

Communities In Schools of the Eastern Pennsylvania, 739 North 12th Street, Allentown, PA 18102

Educational Enterprises, LLC, 2331 Pennsylvania Avenue, Philadelphia, PA 19130
YesNo
I understand that this consent form is otherwise valid for as long as my child is enrolled in his/her current school district.

· I acknowledge that the release of records under this consent is subject to any limitations placed by federal and state law. Signed releases will be obtained for parent/guardian permission in the event of referral.

· I understand that the data and information collected on my student is maintained in a computer database. This information is used by CIS to document services provided to students and families for tracking and reporting purposes. It will be collected on a quarterly basis, and as needed. All student records may be maintained for up to 25 years.

· I give permission for this form to be shared with other districts/CIS sites/CIS staff in the event my student disenrolls from this site/school/district and enrolls elsewhere.

· I also understand that my student’s responses on surveys will be automatically grouped together with the responses of other students for any public presentations of findings, and that my student will not be individually linked to his/her responses.

· I acknowledge that I have the right to inspect and that I can obtain a copy of any record released by this consent upon request in writing to the releasing agency, subject to any applicable copying costs and legal limitations.

· I give my permission to CIS to photograph, film, video and/or make sound recordings of my student, to quote, use my student’s artwork, or publish statements of my student and to use such photographs, films, video, sound recordings, artwork, and/or other statements for educational and promotional/advertising materials.
YesNo
Parent/Guardian Name*
Parent/Guardian Signature*

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Student Name*
Student Signature*

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For more information, please contact Erin Phillips at phillipse@ciseasternpa.org

Funded in full or in part by a grant from the Pennsylvania Department of Education.
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21st CCLC After School Program Application After School Program - Summer and School Year 2025-2026

STUDENT APPLICATION and RELEASE OF INFORMATION FORM

Student Information

Parent/Guardian Information

Program Transporation