If Parent/Guardian cannot be reached, call:

By signing the form, I give permission for my child to attend PAY Afterschool Enrichment Program.  I understand that Lee County Schools and/or the school that my child attends will use regular school buses to transport my student to the afterschool program.  I further agree to release my student to the care and supervision of the 21st Century program.  While transportation service is Mondays through Thursdays, on Fridays your child will continue thier regularly scheduled school route from school to home.  This will continue until the school receives notification to terminate transportation serivces to the Afterschool Enrichment Program.  

I further agree to the authorization to release my student's school records that include but are not limited to Placement Tests, Behavioral Citations, IEP's Reports, Academic Grades, and both EOG and EOC scores to the Program Director's staff upon their request.

FOR TRANSPORTATION OFFICE USE ONLY!  PLEASE DO NOT RESPOND BELOW!!!

I understand that as the parent/guardian of my child, I am responsible for the granting of permission and consent to the following procedures as well as the actions and physical condition of my child while he/she is in the 21st Century Program.  As such I consent to the following:

The 21st Century Afterschool Handbook is currently available at www.pdypay.com.  The Acceptance Use Policy, which gives your student permission to use a computer on our campus, is included in the handbook.  It is REQUIRED that parents and students review the handbook, sign the agreement below and return it to the appropriate personnel.  Students are NOT permitted to use a computer at the program if their policy form is not signed and received by an authorized parent or guardian.  If you cannot access the online version of the handbook, please call the Program Director to request a paper copy.  All contact information can be found on our website at www.pdypay.com.

**THIS FORM MUST BE SIGNED AND ON FILE BEFORE ANY CHILD CAN ATTEND THE PROGRAM!**

I have read the policies outlined in the 21st Century Afterschool Program (PAY) Handbook.  By signing, I am verifying my understanding and adherence of the policies and procedures outlined in the handbook. 

I give my child permission to use the computer and network resources of the program, in accordance with the policies outlined in the 21st Century Afterschool Program (PAY) Handbook.

I have read and understand the rules and regulations put in place for the safety of the students, staff and facility as a result of COVID.

I have read and understand the disciplinary rules and consequences the program has set in place for my child.  I understand that my child may be dismissed from 21st Century Community Learning Center Afterschool Program as a result of continuous disciplinary problems. 

In Response to COVID and ANY OTHER CONTAGIOUS ILLNESSES, please read the following Rules and Regulations that PAY has put in place to ensure the safety of the students, staff and facility!

 

COVID/Contagious Illness Policies and Procedures

1. PAY staff members will be outside to take your child’s temperature before they are allowed to enter!  If ANY child’s temperature exceeds 100.4 degrees, they will NOT be permitted to enter the facility and must immediately return to their car and leave the premises.  Your child will be not permitted to return until their temperature is back to a safe and normal state. 

2. Parents/guardians MUST REMAIN in your vehicle at all times.  Once you pull up to the front building, you must remain in line until your child’s temperature has been approved!  If approved, you may leave.  If not approved, your child must leave with you.

3. Breaks will be taken throughout the day for sanitizing, disinfecting and sterilizing the facility.  This will ensure the safety of our participants and staff. 

4.. In the event that your child gets sick while on the premises, they will be taken to our First Aid area, parents/guardians will be contacted immediately and your child will remain in the First Aid area until they are picked up! 

5. Students experiencing any of the following symptoms must return/remain home until otherwise advised by a doctor or PAY staff member: fever, chills, new cough, shortness of breath, difficulty breathing, fatigue, muscle, body aches, new loss of taste or smell, sore throat, congestion, runny nose, headache, nausea, vomiting, diarrhea, piny eye, rashes, strep throat, etc... 

6. AN EMERGENCY CONTACT MUST BE PROVIDED IN THE EVENT A CHILD IS SICK AND NEEDS TO LEAVE THE PREMISES.  PLEASE ENSURE THAT THIS INDIVIDUAL IS AVAILABLE TO PICK THE CHILD UP IN A TIMELY MANNER! 

7. IF ANY CHILD ATTENDING THE PROGRAM TESTS POSITIVE FOR COVID, THEY WILL NOT BE PERMITTED TO RESUME ATTENDING PDY/PAY UNTIL PROOF OF A NEGATIVE TEST RESULT IS PROVIDED. NO EXCEPTIONS!

8. IF ANY STUDENT ATTENDING PAY COMES IN CONTACT WITH ANYONE THAT TESTS POSITIVE FOR COVID, THE CHILD MUST REMAIN AT HOME UNTIL THE DIAGNOSED INDIVIDUAL TESTS RESULTS ARE NEGATIVE!  NO EXCEPTIONS!

PAY Afterschool Program reserves the right to make decisions, changes and executive calls that are in the best interest of the program participants, staff and facility due to COVID and other contagious illnesses.    

_________________________________________________________________ 

I have read the policies and understand my responsibilities as a parent to keep my child, the program, staff and facility safe.  I have shared this information with my child/ren and they are aware of their responsibility as a student to keep the program, staff and facility safe. 

If my child is experiencing any symptoms of COVID, I will NOT bring them to PAY until they are at a healthy state to return. 

I agree to adhere to the rules and regulations outlined for attendance to PAY Afterschool Program for the 2025-2026 school year.  Failure to follow these guidelines will result in expulsion of my child/ren from PAY Afterschool Program. 

My child and I have read through the PAY Parent Student Handbook and we are aware and understand the Policies and Procedures outlined. 

*****I do hereby understand, acknowledge and accept the risk that my child/ren may be exposed to COVID and/or other illnesses in the care of PAY 21st CCLC Program.  I hereby release Christian Provision Ministries, PAY 21st CCLC from the claims relating thereto.  To prevent the spread of COVID and other viruses and/or illnesses, I agree to follow the guidelines set with PAY and Christian Provision Ministries to keep myself, my child/ren and my community safe. ****