SY24-25 After-School Plus (A+) School Program Registration Form

After-School Plus (A+) School Program Registration Form
The After-School Plus (A+) Program, the first program of its kind in the nation, provides statewide after-school services for public elementary students at affordable rates. The program addresses the “latch- key” child problem by providing a high quality after-school program to children of working parents/legal guardians or children whose parent/legal guardian is engaged in job training or attending school during the hours of A+ operations. If your child qualifies and you want to enroll him/her, please complete both sides of this registration form and return it to your child’s school.
As a parent/legal guardian, do you meet any of the following eligibility criteria:*

Employed during A+ hoursAttend school during A+ hoursWork for an A+ ProgramNone of the Above
Can you provide documentation that you require care during A+ hours?*

YesNo

Based on your responses in the questionnaire, you are currently ineligible to participate in the A+ Program at this time.

Based on your responses in the questionnaire, you are currently eligible to participate in the A+ Program.
Fee: Due Monthly
The monthly fee covers regular program activities. The fee will be adjusted for those who qualify if acceptable supporting documentation about their income or DHS 728 Form is submitted.

Hours: After school - 5:30 p.m.
The program hours are from after school to 5:30 p.m. on regular school days. The program will not operate during school vacations, state holidays, weekends, Teacher Institute Day, Teachers’ work day and school half days.

Supervision: Staff to Student Ratio of 1:20
At each school, the staff will consist of a Site Coordinator and a group leader team supported by aides to maintain a staff to student ratio of 1:20. Staff recruitment may limit the number of students that a school can serve.

Activities: A variety of scheduled activities
Children usually begin the afternoon with free play time and a snack period (children bring their own snacks from home). This period is followed by other activities including homework time, enrichment and physical fitness. Site Coordinators will have the flexibility to adapt scheduled activities to meet the conditions at your child’s school.

Eligibility: K-6 public elementary school latchkey children
Your child is considered latchkey if he/she is living with you and during the hours of A+ operations you are employed, attending school, engaged in a job training program, or working as an employee of the A+ program. A parent/legal guardian who is “self-employed” must verify their status by: a) Submitting a copy of their general excise tax license; and b) submitting a copy of one of the following: 1) income tax return for the past year including Schedule C; or 2) printed business checking account.

Starting Date: Child’s first full day of school
Starting date for your child is usually the first full day of school. However, the starting date of the A+ Program at your child’s elementary school may depend on the after-school enrollment of at least 20 children and the ability to recruit necessary staff.

Family Information
How many children are registering for After-School Plus*
Child resides with*
School Name*
School Phone*
Please enter a valid phone number.
Days Attending*

MondayTuesdayWednesdayThursdayFriday
Language spoken at home*
Ethnicity (Optional)
Today's Date

MonthDayYear
Date

1st Child's Information
Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Date
Age*
A child must be five years of age by July 31 of that school year to enter kindergarten at any public or charter school.
Grade*
Room
Sex*
Hidden Male
Hidden Female
Any other educational/health information about student.

0/50
2nd Child's Information
Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Date
Age*
A child must be five years of age by July 31 of that school year to enter kindergarten at any public or charter school.
Grade*
Sex*
School
Any other educational/health information about student.

0/50
3rd Child's Information
Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Date
Age*
A child must be five years of age by July 31 of that school year to enter kindergarten at any public or charter school.
Grade*
Sex*
School
Any other educational/health information about student.

0/50

How many Parent/Legal Guardian(s) does the child have?*

12

Authorized Individuals for Pick-up

List below adult individual(s) authorized to pick-up your child from the facility and their phone numbers. The child will not be released to any individual not listed below. Any changes in departure authorization must be received in writing from the parent/legal guardian.*

	Individuals First and Last Name	Relationship to Child	Phone Number
1
2
3
4

Confirmation Email Address

Please enter a valid email address below to receive a confirmation email upon submission.
Confirmation Email Address*
example@example.com
Should be Empty:

After-School Plus (A+) School Program Registration Form

Based on your responses in the questionnaire, you are currently eligible to participate in the A+ Program.

Family Information

1st Child's Information

2nd Child's Information

3rd Child's Information

Parent/Legal Guardian's Information - 1

Parent/Legal Guardian's Information - 2

Authorized Individuals for Pick-up

After-School Plus Program Registration Agreement

Parent/Legal Guardian's Responsibilities and Billing Procedures

Fee Procedures

A+ Program Emergency Form

Confirmation Email Address

	Work/School Start Time	AM/PM	Work/School End Time	AM/PM
Monday
Tuesday
Wednesday
Thursday
Friday

	Work/School Start Time	AM/PM	Work/School End Time	AM/PM
Monday
Tuesday
Wednesday
Thursday
Friday