2025-26 Rockdale Bridges Afterschool Program Application

ROCKDALE BRIDGES AFTERSCHOOL PROGRAM

2025 - 2026 SCHOOL YEAR
WHICH SITE DOES YOUR CHILD ATTEND?*
AT THIS TIME YOUR STUDENT WILL BE ADDED TO THE WAIT LIST FOR PEEK'S

You will be contacted by a staff member IF a slot becomes available.
I would also like my child to participate in Peek's Saturday School for the school year.*

YesNo
I would also like my child to participate in Memorial's Morning School for the school year.*

YesNo
STUDENT NAME:*

First NameLast Name
STUDENT BIRTH DATE:*

MonthDayYear
AGE OF STUDENT:*
STUDENT GTID NUMBER (STATE ID #):*
INFINITE CAMPUS - STATE ID #
STUDENT ID NUMBER:*
INFINITE CAMPUS - 778######
STUDENT GENDER:*
ETHNICITY:*
PRIMARY LANGUAGE:*
IF OTHER, ENTER HERE:
GRADE LEVEL 25-26:*
NAME OF HOMEROOM TEACHER:*
STUDENT'S SPECIAL EDUCATION STATUS*

Yes, Special EducationNo, Not Special Education
STUDENT LIVES WITH:*
PARENT/GUARDIAN'S NAME #1:*

First NameLast Name
PARENT/GUARDIAN'S NAME #2

First NameLast Name
HOME ADDRESS:*

Street Address

Street Address Line 2

CityState / 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:*

BusCarWalker
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 NameRelationshipPhone Number
First and Last NameRelationshipPhone 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 ROCKDALE BRIDGES PROGRAM HAVE PERMISSION TO USE PHOTOS OF YOUR CHILD IN EDUCATIONAL OR PROMOTIONAL MATERIALS?*

Yes, Rockdale Bridges has permission to take photos of my childNo, Rockdale Bridges 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 ROCKDALE BRIDGES STAFF TO REVIEW MY CHILD'S ACADEMIC FILE FOR PURPOSES OF ANALYZING EFFECTIVENESS AND REPORTING TO FUNDING SOURCES.*

Clear
AT THIS TIME YOUR STUDENT WILL BE ADDED TO THE WAIT LIST

You will be contacted by a staff member once a slot becomes available.
Should be Empty:

ROCKDALE BRIDGES AFTERSCHOOL PROGRAM

AT THIS TIME YOUR STUDENT WILL BE ADDED TO THE WAIT LIST FOR PEEK'S

PLEASE READ EACH ITEM CAREFULLY AND INITIAL EACH TO SHOW UNDERSTANDING

AT THIS TIME YOUR STUDENT WILL BE ADDED TO THE WAIT LIST