Creative Connections
After-School Enrichment Program
* Please fill out both pages of this form.
Child's Name
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Sex
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DOB
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Grade
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Address
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Home Address
Street Address Line 2
City
State / Province
Zip
Parent/Guardian 1
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Employer
*
Cell Phone
*
Format: (000) 000-0000.
Email
*
example@example.com
Parent/Guardian 2
Employer
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Emergency Contacts and people authorized to pick up child:
Name 1
*
Relationship
*
Phone
*
Format: (000) 000-0000.
Name 2
Relationship
Phone
Format: (000) 000-0000.
Allergies/Dietary Restrictions
*
Other concerns/special needs
*
Medical Provider
*
Phone
*
Format: (000) 000-0000.
Insurance Provider
*
Policy
*
Dentist
*
Phone
*
Format: (000) 000-0000.
Parent or Guardian Authorization:
My child may be photographed for publicity or news purposes.
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Yes
No
My child may be taken on field trips by bus or private motor vehicle, as well as neighborhood walking excursions under required supervision.
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Yes
No
In an emergency, the Creative Connection staff has my permission to call an ambulance, or take my
child to any available physician or hospital at my expense to obtain medical treatment. In most
emergencies, 911 is called and the child will be transported to the nearest hospital and treated by on-
call physician. The parent or guardian will be notified as soon as possible.
Parent/Guardian Signature
*
Date
*
/
Month
/
Day
Year
Date
Please read this information carefully and follow these guidelines and initial each statement.
I have read over the Creative Connections Program and Policies information sheet.
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Payment is due by the 1st day of the month for the upcoming month. A $10 late fee will be added after the 5th of the month. Credit will not be given for sick or missed days.
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I understand the program will operate every school day of the school year, but will not meet on school or legal holidays, or snow days when school is cancelled.
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I will notify Creative Connections in advance if my child will not be attending on a scheduled day or if there are special pick-up arrangements (i.e. someone else picking up child). I will call (541) 488-3019 to leave a message.
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Parents must sign out their child/children daily. Children need to be picked up no later than 5:30pm. If running late, call staff at (541) 488-3019. If late pickups become a pattern, a fee will be added to the next month’s payment.
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Only parents/guardians and parent-authorized people may pick up children. Authorized individuals may be asked for photo ID.
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I give permission for my child to be transported from Ashland Elementary Schools to the Creative Connections site via the Ashland School District bus by completing a Transportation Agreement.
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Children who are ill or have communicable diseases are not allowed to attend.
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I give permission for the staff to respond to and administer minor first aid care.
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All immunizations are current.
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All immunizations are current.
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Yes
No
I endorse the vision of the program and will support the programs goal to provide dailey enrichment in its various ways.
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I have communicated with my child, and they understand that the program will have daily organized activities, and they are expected to participate willingly, respectfully and with a positive mindset.
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Child's Signature
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Parent/Guardian Signature
*
Date
*
/
Month
/
Day
Year
Date
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