BUMC Afterschool Bilingual Program - Enrollment Application

BUMC Afterschool Bilingual Program - Enrollment Application
Student Information

If you have more than one child to register for this program, please fill out a separate application FOR EACH CHILD.
First Name*
Middle Name
Last Name*
Birth Date*

MonthDayYear
School Attending*
Grade Attending*
Name of Homeroom Teacher

First NameLast Name
What days of the week will your child attend the program?*

MondaysTuesdaysWednesdaysThursdaysFridays
Please use this link to read the Afterschool Bilingual Program's policy on communication with Watauga County Schools: Consent for Release and Exchange of Confidential Information with Watauga County Schools and the BUMC Afterschool Bilingual Program.
By signing below, I authorize the release of my child's school records (including, but not limited to: personally identifiable information; permanent cumulative records; special education records; academic transcript; discipline records; health records; attendance records; and test scores) from Watauga County Schools to the BUMC Afterschool Bilingual Program.*

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Parent/Guardian #1 Information
Full Name*

First NameLast Name
Relationship to Child*
Cell*
Work
E-mail*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this the same address as the enrolled child?*

YesNoChild is at this address part-time.
Parent/Guardian #2 Information
Full Name

First NameLast Name
Relationship to Child
Cell
Work
E-mail
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this the same address as the enrolled child?

YesNoChild is at this address part-time.
Authorized Contacts

The parents/guardians listed above are automatically labeled as authorized contacts. Please list additional people authorized to pick up your child from the program.
Contact #1 - Name

First NameLast Name
Contact #1 - Relationship to Child
Contact #1 - Phone Number
Contact #2 - Name

First NameLast Name
Contact #2 - Phone Number
Contact #2 - Relationship to Child
Contact #3 - Name

First NameLast Name
Contact #3 - Relationship to Child
Contact #3 - Phone Number
By signing below, I hereby certify that, to the best of my knowledge, the provided information is true and accurate. *

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Health Care Needs
Does your child have any allergies?*

YesNo
If yes, please list the allergen, the severity of the allergy, and explain the allergic reaction in detail.*
In case of an allergic reaction, please explain what the staff members need to do to help your child.*
Does your child have any medical conditions?*

YesNo
If yes, please name the condition and explain the child's health care needs they will have while at the program.*
REQUIRED MEDICATION ADMINISTRATION

If your child has medicine that they need to take during program hours to stay on their proper schedule, please list them in detail below when prompted. These medications need to meet the requirements in the article listed below. North Carolina School Health Program - Medication Administration Legislative Requirements.
Does your child require any medication during program hours?*

YesNo
If yes, please list the following: name of medication, time/frequency, dosage, route, side effects, and special instructions.*
Do you authorize us to administer the medications listed above?*

YesNo
Please share any other medical information that may be helpful in caring for your child.*
By signing below, I hereby certify that, to the best of my knowledge, the provided information is true and accurate. In the case of an emergency, I authorize Boone United Methodist Church and the staff at the Afterschool Bilingual Program to obtain medical information for my child. I hereby release Boone United Methodist Church, its Afterschool Bilingual Program, staff, and volunteers from any and all liability arising out of any accident that may occur in connection with the operation of the Afterschool Bilingual Program, or from any illness that may be contracted by your child while attending this program.*

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Afterschool Bilingual Program Handbook
Please use this link to read the Afterschool Bilingual Program's Handbook IN FULL: Afterschool Bilingual Program's Handbook
By signing below, I hereby certify that I read the "Afterschool Bilingual Program's Handbook" IN FULL, have discussed its contents with my child, and agree to the its terms and conditions.*

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Behavior, Discipline, and Safety Policy
Please use this link to read the Behavior, Discipline, and Safety Policy Form: Behavior, Discipline, and Safety Policy
By signing below, I hereby certify that I read the "Behavior, Discipline, and Safety Policy" IN FULL, have discussed its contents with my child, and agree to its terms and conditions.*

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Transportation
- Please use this link if your child attends Parkway School.
- Please use this link if your child attends Hardin Park.
- Please use this link to read about methods of transportation home after the Afterschool Bilingual Program ends.
Method of Transportation to the Afterschool Bilingual Program*

Parkway students: I confirm that my child and I have discussed the transportation procedures from Parkway School to Boone United Methodist Church. My child understands the expected behavior during dismissal, the designated meeting point, and the importance of following rules, and cooperating with all staff and volunteers from Parkway School and the Afterschool Bilingual Program.Hardin Park students: I confirm that my child and I have discussed the transportation procedures from Hardin Park School to Boone United Methodist Church. My child understands the expected behavior during dismissal, the designated meeting point, and the importance of following rules, and cooperating with all staff and volunteers from Hardin Park and the Afterschool Bilingual Program.
Method of Transportation Home after the Afterschool Bilingual Program*

I acknowledge that I must pick up my child from BUMC (471 New Market Boulevard, Boone, NC 28607) at 5:30 PM on Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays after the Afterschool Bilingual Program ends.I agree to allow certified staff from BUMC's Afterschool Bilingual Program to take my child home in the designated and approved BUMC van. I acknowledge that the address I provided on these enrollment forms (at the beginning of these forms) is the correct drop-off location for my child.
By signing below, I confirm that my child and I have discussed the transportation methods he/she will use to get to the Afterschool Bilingual Program and to get home after the program ends. This signature signifies our mutual understanding and commitment to adhering to these established transportation protocols for the safety and well-being of all involved. I understand that if my child will be dropped off late, picked up early, or absent from the program, I will communicate the change of plans to the director and/or assistant director of the Afterschool Bilingual Program.*

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Tuition

We never want payments and financial matters to interfere or inhibit the enrollment of your child(ren). Parents/guardians are encouraged to pay tuition, but only if it is feasible for your family.
Please use this link to read the details about tuition options: Tuition.
Tuition Fee Options*

$0 weekly (full scholarship).$5 weekly.$12 weekly.$32 weekly.$52 weekly.$72 weekly (full tuition).
By signing below, I hereby agree that I have read the Tuition Options and Information document and have selected a tuition option that is accurate to my family's needs.*

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Photo and Video Release Form
Please use this link to read the Photo and Video release Form: Photo and Video Release Form.
By signing below, I hereby certify that I read the "Photo and Video Release Form" IN FULL, have discussed its contents with my child, and agree to its terms and conditions.*

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Final Signatures
By signing below, I hereby certify that I have read this electronic form for Boone United Methodist Church's Afterschool Bilingual Program in FULL, have filled it out to the best of my ability, and agree with the program's terms and conditions.*

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BUMC Afterschool Bilingual Program - Enrollment Application

Student Information

Parent/Guardian #1 Information

Parent/Guardian #2 Information

Authorized Contacts

Health Care Needs

Afterschool Bilingual Program Handbook

Behavior, Discipline, and Safety Policy

Transportation

Tuition

Photo and Video Release Form

Final Signatures