26-27 CJ Hicks MORE Before and After School Program Registration Form

Date to start the CJ Hicks Before or After School Program

First day of school is 08-03-2026

Applicant's email address

example@example.com

Student Names

Rows	Last Name	First Name	Grade	Teacher	Age	Gender	Date of Birth
Student 1
Student 2
Student 3
Student 4

Before and/or After Care Selection

Rows	1 child	2 children	3 children
Before Care-6:00 a.m. to 7:00 a.m. $35 per week per child
After Care-2:05 p.m. to 6:30 p.m. $80 per week per child
Before & After Care $105 per week per child

Student(s) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student(s) Legal Guardian(s): Check One

Student(s) Living Arrangements: Check One

Mom's Information

Rows	Response
Mom's Name
Phone Number
Alternate Phone Number
Address if different from child
Place of Employment
Address of Employment
City, State and Zip
Mom's Work Phone

Dad's Information

Rows	Response
Dad's Name
Phone Number
Alternate Phone Number
Address if different from child
Place of Employment
Address of Employment
City, State and Zip
Dad's Work Phone

The following adults, over the age of 18, have permission to pick up my child(ren) from After School, with a picture ID.

Rows	First and Last Name	Cell Phone	Relationship	Address (Street-City-State-Zip)
Mother
Father
Additional Adult
Additional Adult
Additional Adult
Additional Adult

Persons to contact in the case of emergency when parent or guardian cannot be reached:

Rows	First and Last Name	Cell Phone	Relationship
Name
Name
Name

Please indicate your understanding of the After School Payment Options.

Rows	Please select
After School Tuition * Tuition must be paid on or before the first day of attendance for each week, otherwise, a $10 late fee will be charged. * Non-payment of tuition will result in removal from the program. * Credit is not given for days absent. Tuition will be prorated if there is a school holiday. COVID related absence will be handled on an individual basis. * A late fee of $1.00 per minute is charged for the first 5 minutes your child is picked up after 6:30 p.m. At 6:35. the late fee increases to $5.00 per minute. Three late pickups will result in removal from the program. * RCPS charges $35 for returned checks.
After School On-Line Payments * I am interested in making online payments. I understand there is a fee to make online payments.
Monthly Payments * I would like to pay on the first day of the month to save 5% of the tuition fee.
I have applied for and been notified that I am eligible to receive CAPS.
CAPS * If eligible to receive CAPS, I understand I am responsible for payment until my effective CAPS date with the C.J. Hicks MORE After School Program. CAPS does not provide retroactive payments.

Please indicate your understanding of the After School Policies

Rows	Please select
Attendance Before and after school will not be held when school is not in session for students. This includes but is not limited to early release days, independent learning days, school holidays, inclement weather days or other school closing emergencies.
Homework * Homework time is provided. A final check of homework will be done by the parent. * Time is provided for students to do homework from 3:00 p.m. to 4:00 p.m. If the student attends an additional after school club or tutorial, homework assistance may not be available. * There are some activities in which classroom teachers prefer parents to do with their children such as reading to them and student projects.
Pick-Up Information * A picture id is required to pick up all students. * If anyone other than names listed above is picking up your child, we must have a signed note authorizing the pickup from the parent or guardian and the pick-up person must have a picture id. * The pick-up person must be an adult who is at least 18 years of age.
Personal devices * Per RCPS policies and procedures, I understand my child may not use their personal device such as a phone, tablet or computer while in after school.

Please indicate your understanding of the Medical and Educational Information

Rows	Please select
Students experiencing Covid-19 or a contagious illness * Notification of parents in the event their child becomes ill will while in our care will be notified. * Parents of students who come into contact with a reportable contagious illness will be notified. * Students experiencing illness or fever are asked to stay home. * A mask is optional at this time. * Whenever possible, social distancing of staying at least 3 feet apart will be maintained.
Medical Information * Parents assume liability for injuries and accidents incurred and the cost of treatment during the MORE program.
Medicine Authorization * In non-emergency health situations, I authorize the administration of children's fever-reducing/pain killer medication (i.e. Tylenol, Advil, or a generic medication) according to the manufacturer's instructions.
Emergency Medical Attention Authorization * In the event of serious illness or injury, I authorize the school to telephone Emergency Medical Services (911) for the immediate transportation to the nearest hospital. I, the parent/legal guardian, authorize the transport and treatment by the hospital emergency staff for my child.
I authorize the application of nonprescription sunscreen and insect repellent.

My child has the following medical needs.

Rows	Child's Name	Illness	Allergies	Other Medical concerns	Required Medicine	Additional information
Child 1
Child 2
Child 3
Child 4

Child's Doctor or Clinic Name

Rows	Child 1	Child 2 (if differrent)	Child 3 (if different)	Child 4 (if different)
Child's Doctor or Clnic Name
Child's Doctor or Clinic Phone Number

PARENT EMERGENCY MEDICAL AUTHORIZATION

Rows	Student Name	Should my child (ren) suffer an injury while in the care of the C.J. Hicks MORE After School Program and the facility is unable to contact me (us) immediately, the facility shall be authorized to secure such medical attention and care for my child(ren)as may be necessary. I (We) shall assume responsibility for payment services.	Child's Birthdate Include Month, Date and Year	Additional Comments
Student #1
Student #2
Student #3
Student #4

Parent/Guardian EMERGENCY MEDICAL AUTHORIZATION SIGNATURE

Should my child (ren) suffer an injury while in the care of the C.J. Hicks MORE After School Program and the facility is unable to contact me (us) immediately, the facility shall be authorized to secure such medical attention and care for my child (ren)as may be necessary. I (We) shall assume responsibility for payment services.

EMERGENCY MEDICAL AUTHORIZATION DATE

Date

My child has the following educational needs

Rows	Child's Name	Educational accommodations	My child has an IEP-Individual Education Plan	My child has a 504 Plan
Child 1
Child 2
Child 3
Child 4

Additional Comments-Please let us know if there is anything else we need to know about your child or children.

If school closes due to inclement weather or other emergency, the MORE program will not be in operation. If this occurs, the parent will be notified.

Rows	Please enter information
My child rides bus number
Alternate provisions

For RCPS employees only.

Rows	School	RCPS eMail Addess
I am a RCPS employee

C.J. Hicks MORE After School Parent Handbook

I First Name Last Name , the parent of First Name Last Name ,

I acknowledge that I have been informed that the CJ Hicks MORE After School Program is not a Georgia Department of Early Care and Learning licensed child care facility. I also understand the CJ Hicks MORE After School Program is not required to be licensed by the Georgia Department of Early Care and Learning and this program is exempt from state licensure requirements.

Signature Date

I have read and agree to the C.J. Hicks MORE After School Procedures, Policies and Weekly or Monthly Payment Schedule. Parent's Signature

School: C.J. Hicks

2026-2027 CJ Hicks MORE Before and After School Program Registration Form

Student Information

After School Flyer

Parent Signature is Required