LNS -After School Enrichment 2025-2026

Please make sure EVERY box is filled out before turning in your student's application. We need current medical information and working phone numbers for all contacts in case of an EMERGENCY.
Todays date*

MonthDayYear
Date
Current School*
Current Grade (2025-2026)*
STUDENT INFORMATION
First*
Last name*
Middle*
SPED?*

YesNo
Birth Date:*

MonthDayYear
Date
Age*
Gender:*

MaleFemale
PARENT/GUARDIAN INFORMATION
First*
Last name*
Email*
example@example.com
Cell Phone*
Home Phone*
First*
Last name*
Email*
example@example.com
Cell Phone*
Home Phone (2)*
ADDRESS: WHERE STUDENT WILL BE PICKED UP AND DROPPED OFF DAILY
Street*
Apt*
City/State*
Zip Code*
EMERGENCY CONTACTS
First*
1 Last name*
Cell Phone*
Home Phone*
First*
2 Last name*
Cell Phone*
Home Phone*
HEALTH CONDITIONS:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize LNS 21st Century or insurance company to release any information required to process my claims.
SCHOOL HEALTH/MEDICATION FORM
Student Name*
Physician Name*
Physician Address*
MEDICATIONS
Medication
Reason for medication
Medication dose
Directions
Direction for medication
Medication taken on site:

YesNo
*If yes, you must see the LNS school nurse for a form to take to your physician
My child has a life-threatening condition – please notify the nurse:*

YesNo
ALLERGY INFORMATION
Student Allergy:*

NoneFoodMedicationEnvironmental
Describe allergies
Required treatment
Does student carry a medical device?

YesNo
The prescribed device is:

InhalerEpi PenOther
All emergency medical devices (inhalers, EpiPens, etc.) must be carried on the individual’s person or with the nurse,while attending after school enrichment. I,
Parent/Guardian:
hereby request that
Student:
be allowed to keep the appropriate prescribed device on his/her person or with thenurse, while participating in after school enrichment program.
OTHER HEALTH CONCERNS
Please describe any other health concerns
AUTHORIZATION FOR EMERGENCY PROCEDURE
I hereby certify that the above information is correct. I am authorized to provide the medical information and release the authorization contained herein and agree to release Lummi Nation School and its agents from all liability arising because of this waiver. If the parents and authorized physician named on the registration record cannot be reached at the time of an emergency and the immediate observation or treatment is urgent in the judgment of the school authorities, I authorize and direct the school authorities to send the accompanied child to the hospital or doctor most easily accessible. I understand that I will assume full responsibility for the payment of any services rendered.
Signature*

Clear
Date*

MonthDayYear
Date
AUTHORIZATIONS
FIELD TRIPS/STUDENT TRAVEL
I give permission for my child to participate in classroom/school field trips. I also give permission for my child to be transported by Lummi Nation School, J.O.M., Youth Outreach, or LTHC employees as deemed necessary for school or emergency related purposes. I understand that students are expected to remain with the group unless written permission is given by me to do otherwise.*

YesNo
AUTHORIZATION FOR PICK UP
The following people are authorized to pick up my child/children:
Name*
Cell phone #*
Name*
Cell phone #*
Name
Cell phone #
Name
Cell phone #
PHOTOGRAPHY RELEASE
I give permission to use and reproduce my child's name/image for promotional purposes related to Lummi Nation School and the 21st Century grant*

YesNo
CODE OF CONDUCT/RULES/EXPECTATIONS
I have read, understand, and have reviewed with my child the Lummi Nation School Policies and Procedures found at: https://www.Ins-onlinelearning.org/ files/ugd/cb3d79 86918fc5a212437a9233eb3ec4ad3ed2.pdf
I acknowledge that my child/children will be subject to all Lummi Nation School's Policies and Procedures while attending the after-school enrichment program.*

YesNo
PARENT/GUARDIAN AUTHORIZATION
I certify that I understand and have given consent to the above waivers, releases, and permissions.
Signature*

Clear
Date

MonthDayYear
Date
After School Enrichment Program Behavior Agreement
Dear Families,

Welcome to our After School Enrichment Program! We're excited to give our amazing K-6th grade students the chance to keep learning and growing with us beyond the regular school day. Our program will consist of four 6-week sessions where students can choose one club per session in which to participate. To ensure that participants can feel safe, have fun, learn lots, and have the best possible experience, we will be following a behavior policy that supports a positive and respectful learning environment. We ask that you review the following agreement with your student, sign, and return before their first day. All LNS disciplinary policies and procedures are still in effect after school.

Student Behavior Expectations
1. Be Respectful
  Use kind words and actions. Treat others the way you want to be treated.
2. Listen and Follow Directions
  Pay attention and do your best to follow instructions the first time.
3. Keep Your Body Safe
  Keep your hands and feet to yourself. Have a calm body.
4. Stay with the Group
  Be where you're supposed to be and participate.
5. Take Care of Our Space
  Clean up after yourself and take care of materials.
Consequences
If a student does not meet these expectations, the following steps will be taken:

1. Verbal Reminder - Student is reminded of the behavior expectations.

2. Time to Reflect - Student takes a brief break to calm down and reset.

3. Guardian Notification - A staff member will contact the guardian if the behavior continues.

4. Suspension or Removal from Program - Ongoing or serious behavior issues may result in temporary or permanent removal from the program.

5. Physical violence and bullying behavior will not be tolerated and will result in removal from the

Acknowledgment and Agreement

By signing below, I acknowledge that I have read and understand the expectations and consequences for the After School Enrichment Program. I understand that participation in the program is a privilege, and I will support the program staff in promoting a safe, respectful, and fun environment for all students.
Student Name*
Grade*
Student Signature*

Clear
Parent/Guardian Name Printed*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Lummi Nation School 2334 Lummi View Drive Bellingham, WA 98226
Should be Empty:

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACTS

SCHOOL HEALTH/MEDICATION FORM

MEDICATIONS

ALLERGY INFORMATION

OTHER HEALTH CONCERNS

AUTHORIZATION FOR EMERGENCY PROCEDURE

AUTHORIZATIONS

FIELD TRIPS/STUDENT TRAVEL

AUTHORIZATION FOR PICK UP

PHOTOGRAPHY RELEASE

CODE OF CONDUCT/RULES/EXPECTATIONS

PARENT/GUARDIAN AUTHORIZATION

After School Enrichment Program Behavior Agreement