Afterschool Registration Form
Decatur Housing Initiatives After School Program
About the Program:
The Decatur Housing/Decatur Housing Initiatives After-School Program provides a safe, supportive environment where students receive: Academic tutoring (Grades K–12) College counseling and preparation (for high school students) Enrichment activities that support academic and social-emotional growth The program is held at 481 Electric Avenue and runs every Tuesday through Thursday from 4:00 PM to 6:00 PM during the school year. After submitting the registration form, families will receive confirmation in late August regarding acceptance, waitlist status, and mandatory parent orientation. This communication will come by email. All accepted families will also receive a program start announcement in early September, including detailed information about the schedule, expectations, and next steps.
Section 1: Student(s) Information
Child 1: Name
First Name
Last Name
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Child's Date of Birth
-
Month
-
Day
Year
Date
Grade Level
Please Select
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
Teacher's Name
School Name
Child 2: Name
First Name
Last Name
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of
Child's Date of Birth
-
Month
-
Day
Year
Date
Grade Level
Please Select
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
Teacher's Name
School Name
Child 3: Name
First Name
Last Name
File Upload: Upload a Recent Photo of Your Child
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Child's Date of Birth
-
Month
-
Day
Year
Date
Grade Level
Please Select
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
Teacher's Name
School Name
Child 4: Name
First Name
Last Name
File Upload: Upload a Recent Photo of Your Child
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Child's Date of Birth
-
Month
-
Day
Year
Date
Grade Level
Please Select
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
Teacher's Name
School Name
Section 2: Parent/Guardian Info
Parent/ Guardian Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Property
Please Select
Trinity Walk
Allen Wilson
Swanton Heights
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Unit Number
Section 3: Emergency Contract
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Section 4: Medical and Allergy
Allergies/Medications
Yes
No
If yes, list accommodations.
Section 5: Program Participation
Check all that apply.
Homework Help/Tutoring
College Tutoring Counseling
Enrichment Activities
Section 6: Authorized Pick-Up
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Section 7: Permissions and Agreements
Check all to agree with the terms below.
I give permission for my child to participate in the Decatur Housing Initiatives After School Program.
I understand the program and promptly at 6:00 pm, I (or an authorized adult) will pick up my child on time.
In case of emergency, I authorize program staff to seek appropriate medical care.
I give permission for Decatur Housing Initiative staff and tutors to contact my student/s teacher/s regarding grades and educational progress.
Section 8: Photo Release Authorization
I grant permission for my child's image, video, or voice recording to be used by Decatur Housing/Decatur Housing Initiatives for promotional and educational purposes.
YES—I authorize media use
NO—I do not authorize my child to appear in any media
Submit
Program Information:
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