2026-27 Jericho ALP Registration Form

Jericho After-School Learning Program Registration 2026-27
TEMPORARY HOLD ON NEW REGISTRATIONS
Our After School Program begins September 14th!

We have placed a temporary hold on new registrations at this time.

You CAN still submit a registration, but please DO NOT send your child to the program until you have received confirmation from Jericho that your child is approved to start.

Once you register, we will need a few days to process your child's paperwork and confirm that:
- We have received a current physical
- Payment arrangements are complete
- Transportation has been confirmed
Please wait to hear from us with your child's confirmed start date before sending them to the program.

Thank you for your patience and understanding as we work to make sure every student is properly enrolled and ready to begin!

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/260092140529148

Once you have obtained your family identification number, return to this form to complete your registration for the after-school program.
If you have any problems with your Family ID number please email Dotsy@jerichopartnership.org or call the main office (475) 259-3467
Preferred Language
Family ID
Enter only the numbers after JYM
Which program are you registering for?
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.

If you opt NOT to apply for Care4Kids, and your child will be age 5-12, the Program Cost will be $70/month per child. ($50/month if they attend at Maple Avenue)

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. (NOTE - we WILL require proof of application to C4K.) This scholarship will be awarded to EVERYONE who applies and will bring your fee down to $35/month per child for elementary students or $20/month per child for Middle and High School students.

We do have a family max of no more than $55/month, per family, providing you apply for Care4Kids if your child is under age 13.

	Care4Kids	Jericho Scholarship (Available to students aged 13 and up AND to families that have been denied by Care4Kids)
Children aged 5-12	As low as $.00/month	$35.00/month
Children aged 5-12	I choose not to apply.	$70.00/month or $50.00/month for Maple
Children aged 13 & up	Not eligible	$20.00/month
Family Maximum		No family will pay more than $55/month per family unless they refuse to apply for Care4Kids, in which case the cost will be $70/month ($50/month for Maple Ave) per child.

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 not paid by the 15th of the month, you will be charged a $10 late fee which must be paid prior to your child attending the following month.
If payment is 14+ days late: Your child’s spot may be given to another student.

Scholarship Info
Grade Fall of 2026
Name of School student will attend Fall 2026
Student Information
Student Name

First NameLast Name
Gender
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Information
Parent/Guardian #1 Name

First NameLast Name
Parent/Guardian #1 Cell Number
Format: (000) 000-0000.
Parent/Guardian #1 Email
example@example.com
Parent/Guardian #1 Home Address

Street Address

CityState

Zip Code
Parent/Guardian #1 Employer
Parent/Guardian #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address of Parent/Guardian #1 Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #2 Cell Number
Format: (000) 000-0000.
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Address if different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Parent/Guardian #2 Employer
Parent/Guardian #2 Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address of Parent/Guardian #2 Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information - Please supply 2 contacts OTHER than parents.
Emergency Contact's Name

First NameLast Name
Relationship
Cell Phone Number
Format: (000) 000-0000.
Emergency Contact's Name

First NameLast Name
Relationship
Cell Phone Number
Format: (000) 000-0000.

Health Questions

PLEASE NOTE! ALL STUDENTS MUST HAVE A CURRENT PHYSCAL (DATED WITHIN 3 YEARS) ON FILE PRIOR TO ATTENDING THE PROGRAM!
Insurance Carrier
Insurance ID#
Child's Physician
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Dentist
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the student prescribed an inhaler or epi-pen?
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.
Does your child have allergies to any medication or food?
If Yes, Please explain:
Does your child take any medication daily or occasionally as needed?
If Yes, Please explain:
Does your child have any problems with vision, hearing, speech (i.e., glasses, contacts, ear tubes, hearing-aids, etc.)?
If Yes, please explain:
I give my consent for the First Aid and CPR certified staff of Jericho Partnership, Inc. to administer first aid and CPR to my child and to contact the above named physician or dentist if my child has a medical emergency. I also give my consent for my child to be transported to the nearest hospital in the event of a medical emergency. I will be responsible for all medical fees.
Preferred Medical Facility:
(Name of Hospital)
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

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.
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.
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.
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.
Parent's Name

First NameLast Name
Signature
Parent Signature

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.Format: (000) 000-0000.
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
- Written or oral reports related to my child’s mental health, as shared by the school or related service providers
- Individualized Education Program (IEP) documents and information related to my child’s learning disability
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Printable Documents and Acknowledgment
The following documents are included as part of this registration. By submitting your registration, you acknowledge that you have read, understood, and agree to the terms and policies outlined in these documents.

Please click on each document below to open, review, or print it.

Parent Handbook - English:

https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:6a2451ba-ff3b-4ab3-9915-93b2137d6467

Manual para padres - Español:

https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:e5ca0c19-5126-4980-9a71-5ab473c4c1c7

Manual para os Pais – Português:

https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:73db0df0-1d77-48f5-90ac-32787b40d8f2

Parent Contract/Terms of Agreement - English:

https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:c56bd4b2-a838-4caa-a450-d71ecfc5ba95

Contrato para padres/Términos del acuerdo - Español:

https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:73fc57d0-cbaa-40b8-ad0b-884cb604374e

Contrato/Termos de Acordo para Pais – Português:

https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:7f27e5b0-d21f-4626-b0ef-6d687a54d605

Behavior and Discipline Policy - English:

https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:72178926-16f0-436c-b224-c8535b48b557

Política de comportamiento y disciplina - Español:

https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:b3844d2a-8d0c-4182-ab59-312324fe3c3f

Política de Comportamento e Disciplina – Português:

https://acrobat.adobe.com/id/urn:aaid:sc:VA6C2:f5686daf-6d32-4a3f-9a4a-7eb4df95aa11
My signature below indicates I have read, understood and agree to the terms and policies outlined in these documents above.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

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
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Jericho After-School Learning Program Registration 2026-27

TEMPORARY HOLD ON NEW REGISTRATIONS

Health Questions

General releases and permission

Parental Release Form

Student Information

Parent/Guardian Information

Printable Documents and Acknowledgment

My signature below indicates I have read, understood and agree to the terms and policies outlined in these documents above.

Signature & Confirmation