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THRIVE AFTERSCHOOL PROGRAM
2025 - 2026 SCHOOL YEAR
STUDENT NAME:
*
First Name
Last Name
STUDENT BIRTH DATE:
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
AGE OF STUDENT:
*
Please Select
7 Years Old
8 Years Old
9 Years Old
10 Years Old
11 Years Old
STUDENT GTID NUMBER (STATE ID #):
*
INFINITE CAMPUS - STATE ID #
STUDENT ID NUMBER:
*
INFINITE CAMPUS - 778######
STUDENT GENDER:
*
Please Select
Male
Female
ETHNICITY:
*
Please Select
Asian
Black
Hispanic
Native American
White
Two or More Races
PRIMARY LANGUAGE:
*
Please Select
English
Spanish
Other
IF OTHER, ENTER HERE:
GRADE LEVEL 25-26:
*
Please Select
2nd Grade
3rd Grade
4th Grade
5th Grade
NAME OF HOMEROOM TEACHER:
*
STUDENT'S SPECIAL EDUCATION STATUS
*
Yes, Special Education
No, Not Special Education
STUDENT LIVES WITH:
*
Please Select
Both Parents
Single Mother
Single Father
Foster Parents
Grandparents
Guardian
Other
PARENT/GUARDIAN'S NAME #1:
*
First Name
Last Name
PARENT/GUARDIAN'S NAME #2
First Name
Last Name
HOME ADDRESS:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PARENT/GUARDIAN CELL NUMBER #1:
*
EMAIL:
*
example@example.com
PARENT/GUARDIAN CELL NUMBER #2:
EMAIL:
example@example.com
SIBLINGS, IF ANY (LIST NAME, GRADE AND SCHOOL):
*
Type NONE if there aren't any
MODE OF TRANSPORTATION HOME:
*
Bus
Car
Walker
IN THE EVENT OF AN EMERGENCY HOW WILL YOUR CHILD GET HOME? (I.E. INCLEMENT WEATHER, SUDDEN SCHOOL CLOSURE, ILLNESS)
*
EMERGENCY CONTACT: NAME OF PERSON(S) ALLOWED TO PICK UP YOUR CHILD.(PERSON MUST SHOW A PICTURE I.D. TO PICK UP YOUR STUDENT)
*
First and Last Name
Relationship
Phone Number
First and Last Name
Relationship
Phone Number
IS YOUR CHILD UNDER MEDICAL CARE OR TAKING ANY MEDICATIONS?
*
Yes, my child takes medication(s)
No, my child does not take medication(s)
IF YES, PLEASE LIST DETAILED MEDICAL NEEDS OF THE STUDENT.
*
Type NONE if there aren't any
DOES YOUR CHILD HAVE ANY ALLERGIES, SPECIAL NEEDS, OR DISABILITIES? IF SO, PLEASE LIST BELOW.
*
Type NONE if there aren't any
DOES THRIVE AFTERSCHOOL PROGRAM HAVE PERMISSION TO USE PHOTOS OF YOUR CHILD IN EDUCATIONAL OR PROMOTIONAL MATERIALS?
*
Yes, THRIVE Afterschool Program has permission to take photos of my child
No, THRIVE Afterschool Program does not have permission to take photos of my child
PLEASE READ EACH ITEM CAREFULLY AND INITIAL EACH TO SHOW UNDERSTANDING
CAR RIDERS ONLY - I UNDERSTAND THAT I AM EXPECTED TO PICK UP MY CHILD(REN) ON-TIME EACH DAY BY THE END OF THE PROGRAM DAY.
*
I UNDERSTAND THAT MY CHILD MAY BE DISMISSED FROM THE AFTERSCHOOL PROGRAM AFTER HAVING FOUR CONSECUTIVE UNEXCUSED ABSENCES.
*
I UNDERSTAND THAT I MAY BE CALLED TO PICK UP MY CHILD IF HE/SHE IS DISMISSED FROM CLASS FOR INAPPROPRIATE BEHAVIOR.
*
I UNDERSTAND THAT MY CHILD MAY BE DISMISSED FROM THE AFTER SCHOOL PROGRAM IF THEY RECEIVE A DISCIPLINE REFERRAL.
*
I UNDERSTAND THAT ROCKDALE BRIDGES PROGRAM IS A FREE AFTERSCHOOL PROGRAM FUNDED BY GEORGIA DEPARTMENT OF EDUCATION. BY SIGNING YOUR NAME AND THE DATE, I GIVE PERMISSION FOR THRIVE AFTERSCHOOL PROGRAM STAFF TO REVIEW MY CHILD'S ACADEMIC FILE FOR PURPOSES OF ANALYZING EFFECTIVENESS AND REPORTING TO FUNDING SOURCES.
*
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