Jericho ALP Registration Form 2025-26

Jericho After-School Learning Program Registration 2025-26
**Notice Regarding Program Enrollment**

At this time, we are no longer accepting students directly into the program due to limited transportation availability. However, you may continue with the registration process if you would like your child to be placed on our waiting list.

As soon as we are able to accommodate more students with transportation, we will begin enrolling from the waiting list in the order received.

Thank you for your understanding.
Please note: You must have a Family ID Number in order to register for the After School Learning Program. If you have not yet registered for and received your Family ID Number, please use the link below to complete that process.

https://form.jotform.com/23332433912214

Once you have obtained your Family ID Number, return to this form to finish your after school program registration.
If you have any problems with your Family ID number please email Dotsy@jerichopartnership.org or call the main office (203) 791-1180
Family ID Number*
Enter only the numbers after JYM
Preferred Language*
Which program are you registering for?*

Grade K-5: 44 Spring Street/2 National PlaceGrade 6-12: 22 Maple Avenue
Transportation Notice – Jericho After School Program

We pick up from all Danbury middle schools as well as from DHS, DHS-West and Abbott Tech - and the following elementary schools: Park Ave, Morris Street, Ellsworth, South Street.

Danbury PS buses students from: King Street Schools, AIS, Great Plain, and St. Peter’s.

Other schools: Families are responsible for transportation. No pick-up from Shelter Rock, Stadley Rough, Mill Plain, Pembroke, or Hayestown.
Days and Hours:

The after school program runs from after school until 5:30, Monday - Thursday. Please note, we are CLOSED on Fridays! Please make other arrangements for your child for Fridays.

Additionally, we follow the Danbury Public School calendar. This means that when they are closed, we are closed. This includes half-days. On all early release days, our program is closed and your child will be bussed directly home.

COST OF PROGRAM – IMPORTANT INFORMATION
Jericho Partnership is committed to keeping our After-School Learning Program affordable for Danbury Public School families. On average, it costs Jericho about $75 per child, per week, to operate the program. We understand that paying this full amount could place a financial burden on families, so we have developed a plan to help make the program more affordable.

Step 1: Apply for Care4Kids
If your child is under 13 years of age, apply for Care4Kids funding.
If approved, Care4Kids will pay all or part of your child’s fee.
If denied or placed on a waiting list, you may apply for a Jericho Scholarship to help reduce the cost.
Program Cost=$70/week per child.

The price is the same every week — even for:

Half-days
Weather or emergency closures
Weeks your child does not attend

This is because we are holding your child’s spot and cannot offer it to another student.

Step 2: Apply for Jericho Scholarship

If you have applied for Care4Kids and have either been denied or placed on the waiting list, or if your child is 13 years old and over, please let us know and you will be eligible for the Jericho Scholarship. This scholarship will be awarded to EVERYONE who applies and will bring your fee down to $25/month per child for elementary students or $10/month per child for Middle and High School students.

	Care4Kids	Jericho Scholarship
Children aged 5-12	As low as $.00/month	$25.00/month
Children aged 13 & up	Not eligible	$10.00/month

Payment Schedule
Fees are due prior to attendance

Example: September’s payment is due before your child starts the program.
October’s payment is due by September 29.
If payment is not made before the month begins: Your child cannot attend until the fee is paid in full.
If payment is 14+ days late: Your child’s spot may be given to another student.

Scholarship Info*

I will apply for Care4KidsPlease include me in the Jericho Scholarship (No application needed. Everyone who is on the list will receive the schoalrship!)
Grade Fall of 2025*
Name of School student will attend Fall 2025*
Student Information
Student Name*

First NameLast Name
Gender*

MaleFemale
Birth Date*

MonthDayYear
Date
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
Email*
example@example.com
Home Address*

Street Address

CityState

Zip Code
Parent/Guardian #2

First NameLast Name
Cell Number
Email
example@example.com
Emergency Information - Please supply 2 contacts OTHER than parents.
Emergency Contact's Name*

First NameLast Name
Relationship*
Cell Phone Number*
Emergency Contact's Name*

First NameLast Name
Relationship*
Cell Phone Number*

Health Questions

PLEASE NOTE! ALL STUDENTS MUST HAVE A CURRENT PHYSCAL (DATED WITHIN 3 YEARS) ON FILE PRIOR TO ATTENDING THE PROGRAM!
Is the student prescribed an inhaler or epi-pen?*

YesNo
If yes, please explain.*
I further understand that if my child requires an inhaler, epi-pen or any other medication, my child will not be allowed to attend Jericho's youth program until I have supplied Jericho with the medication(s), an Authorizaton for the Administration of Medication form, AND a copy of the current Individual Care Plan, signed by parent and physician.*

Acknowledged and Agreed
Does your child have allergies to any medication or food?*

NoYes
If Yes, Please explain:
Does your child take any medication daily or occasionally as needed?*

NoYes
If Yes, Please explain:
Does your child have any problems with vision, hearing, speech (i.e., glasses, contacts, ear tubes, hearing-aids, etc.)?*

NoYes
If Yes, please explain:

General releases and permission

Photo/Video Release
I grant/deny permission to Jericho Partnership, Inc. to use the image of my child as marked by my selection below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos and digital images such as those on the Jericho Partnership website.*

Grant unrestricted permission for my child’s image as stated above.Deny permission to use my child’s image at all.
I give permission for my child to be transported as needed in a Jericho van. My signature indicates that I release and discharge Jericho Partnership, Inc., its officers, directors, employees, volunteers, and partners from any and all liability, loss, damage or claims whatsoever that may arise in connection with the above. I understand that Jericho Partnership, Inc. will not be held responsible for injuries, accidents or a loss of valuables while students are being transported.*

YesNo
I hereby give my approval for my child’s participation in any and all activities prepared by Jericho Academic Tutoring Program. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Jericho Partnership. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from Jericho Youth Porgams. In case of injury to said child, I hereby waive all claims against Jericho Partnership. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.*

Consent and acknowledgment given
By checking below, I give my consent for my child/children to walk to their home or other destination I direct after their daily participation in the Jericho After SChool Learning Program, daily. I accept full responsibility for my child and any risk he/she may encounter once he/she leaves the Program each day.*

No, my child will NOT walk home.Yes, my child may walk home.

Behavior and Discipline Policy
At Jericho’s After School Learning Program, we believe in fostering a positive and respectful environment where children can learn and grow. Our approach to behavior management emphasizes understanding, guidance, and encouragement rather than punishment. This section outlines the strategies and principles we use to guide children's behavior.

Guiding Principles

1. Respect and Empathy: All children are treated with respect and encouraged to show kindness to others.

2. Consistency: Clear and consistent boundaries help children understand expectations and feel secure.

3. Positive Reinforcement: Good behavior is acknowledged and rewarded through praise and encouragement.

4. Problem-Solving: We encourage children to think critically and find solutions to conflicts with guidance.

Behavior Guidance Strategies

1. Setting Clear Expectations:

○ We communicate age-appropriate rules and routines in a positive manner.

○ Rules are simple and consistently reinforced (e.g., "We use gentle hands," "We take turns").

2. Modeling Appropriate Behavior:

○ Teachers and staff model kindness, patience, and problem-solving techniques.

3. Redirection:

○ When inappropriate behavior occurs, children are gently redirected toward positive activities.

4. Encouraging Communication:

○ We teach children to express their feelings and needs using words or other appropriate methods.

5. Natural Consequences:

○ Whenever possible, children experience natural consequences of their actions (e.g.,cleaning up after spilling).

6. Time to Reflect:

○ If needed, children may be given a brief, supervised “cool-down” period to reflect on their actions. This is not a punishment but an opportunity for self-regulation.

Prohibited Practices

To ensure a nurturing and safe environment, the following practices are strictly prohibited:

● Corporal punishment (e.g., spanking, hitting)

● Verbal abuse, ridicule, or harsh language

● Withholding food, rest, or comfort as a form of discipline

● Isolating or ignoring children as punishment

Handling Challenging Behaviors

1. Observation and Documentation:

○ Teachers observe and document recurring challenging behaviors to identify triggers or patterns.

2. Collaboration with Parents:

○ Parents will be informed promptly if a behavior persists.

○ Together, we will create an action plan to address the behavior in a consistent and supportive manner.

3. Individualized Support Plans:

○ If needed, a child may receive individualized attention or referrals for additional support (e.g., child psychologists, therapists).

Conflict Resolution and Peer Disputes

When children have conflicts with peers, we guide them through the following steps:

1. Calmly stop any unsafe behavior.

2. Help children express their feelings and listen to one another.

3. Brainstorm solutions together.

4. Encourage reconciliation and guide them to resume play cooperatively.

Parental Communication

We maintain open communication with parents regarding their child's behavior, both positive and challenging. Updates are shared through:

● Daily notes or conversations at pick-up/drop-off.

● Scheduled parent-teacher conferences.

● Immediate contact for serious incidents or safety concerns.

By working together, we aim to nurture children’s social-emotional skills, helping them to develop self-discipline, empathy, and respect for others.

Parent Acknowledgment of Behavior and Discipline Policy

I acknowledge that I have received, reviewed, and understand the Behavior and Discipline Policy of Jericho Partnership's After School Learning Program. I agree to support these guidelines and collaborate with the staff to promote a positive and nurturing environment for my child. I understand the center's approach to behavior management and agree to partner with the program in addressing any behavioral concerns should they arise. By signing this form, I confirm that I have read the policy and will adhere to the practices outlined in it.
Parent's Name

First NameLast Name
Signature*

Clear

Parent Contract/Terms of Agreement
- I understand that the program ends at 5:30 and I agree to pick-up my child on-time. I agree to call the program and let them know if I cannot be on time for whatever reason. Please note that repeat instances of late pick-up may be subject to an additional fee and/or suspension the following day.
- Anyone picking up my child must be at least 18 years of age (unless specifically authorized by me) and should be prepared to show a photo ID when picking up a child from the program.
- I acknowledge the possibility that my son/ daughter may be injured as a result of his/her participation in program activities. I will not make the Jericho After School Learning Program, its instructors, administrators or personnel responsible for any injury that my child suffers as a result of these activities.
- I give permission to the Jericho After School Learning Program to ask my child to complete surveys evaluating various aspects of the learning program. I understand that all information collected regarding my child will be kept confidential.
- In case of personal injury to my child(ren), I hereby waive any and all claims against any person who on behalf of the Jericho After School Learning Program is involved in the transportation of my child(ren).
- I hereby consent to emergency medical treatment of my child(ren) to assure prompt treatment and prevention of undue delay, and I will be responsible for ambulance and medical costs.
- I understand that emergency and health information in the program records must be kept current. I will advise the Director in writing of any changes in my information.
- If my child(ren) becomes ill, either an authorized person or I will be called to pick up the child(ren). (must be 18 or older)
- In order to maintain a safe and fun program, I will work with program staff to ensure proper behavior. Children who exhibit behavior negative to the program may require a parent meeting and the development of a Behavior Plan. Any persistent or severe behavior problems by my child may result in suspension or termination from the program; funds will not be returned. In good faith the program makes every effort to the continued enrollment of the children.
- Parents and Guardians are expected to show respectful behavior at all times while in the Jericho After School Learning Program, on field trips or special events. Any disrespectful behavior including foul language, yelling, intimidation of children or staff, or other threatening type behavior may result in termination of my family from the program. In this case, funds will not be returned.
  I have fully read, understood and accept the above policies and I agree to abide by all program policies. I recognize the Jericho After School Learning Program is relying on my acceptance in permitting my child(ren) to participate in the Jericho After School Learning Program activities.
Parent Signature

Clear

Parental Release Form
Student Information
School Student ID Number*
Date of birth*

MonthDayYear
Date
Student Name*

First NameLast Name
Grade*
School Attending*
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Relationship to Student*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorization and Consent:
I, the undersigned parent/guardian of the above-named student, hereby grant permission for my child’s following assessments and reports to be shared with Jericho Partnership:

Assessment and Reporting:
I acknowledge that my child's progress may be assessed using the following reports:
- Most recent report card
- I-Ready Benchmarks
- Smarter Balance Assessment
- K-2nd: Internal Benchmarks
- 3rd-5th: State Assessments
- K-3rd: DIBELS
Liability Waiver:
I understand and agree that Jericho Partnership and its staff, volunteers, or affiliates will utilize this information to help support my child’s academic progress and will not make this information available to the public, other than in generic summaries that do not specifically name my child.

Acknowledgment and Signature:
By signing below, I acknowledge that I have read and understand this Parental Release Form and agree to its terms.
Signature*

Clear
Date*

MonthDayYear
Date

Signature & Confirmation

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature (Type full name of person authorized)*
Today's Date

MonthDayYear
Date
Should be Empty:

Jericho After-School Learning Program Registration 2025-26

Health Questions

General releases and permission

Behavior and Discipline Policy

Parental Release Form

Student Information

Parent/Guardian Information

Signature & Confirmation