If you have NOT registered with First State in the last 12 months or if you are not sure if you are registered, please go to:

FSCAA/REGISTER

and register your household BEFORE completing this application!  Failure to register for services may delay the processing of your application.

Health Insurance: I understand that if emergency medical care is necessary and I cannot be reached, I authorize First State C.A.A. to act in my behalf in granting permission for my child to receive emergency medical treatment. Parents are responsible for all expenses incurred as the result of medical treatment.

If emergency medical care is necessary for any child I have enrolled in this program and I cannot be reached, I authorize First State Community Action Agency, Inc. to act on my behalf in granting permission for my child(ren) to receive emergency medical treatment.  I understand that I am responsible for all expenses incurred as a result of medical treatment.

Liability Release: I, the undersigned, do hereby agree to release from liability and to idemnify and hold harmless First State Community Action Agency, Inc. and any of its employees or agents representing or related to First State Community Action Agency in regards to the First State CAA After School Program.  This release is for any and all liability for personal injuries (including death) and property losses or damage occassioned by, or in connection with, any activity or accomodations for the First State CAA After School Program.  I further agree to abide by all the rules and regulations set forward by First State Community Action Agency.

For your child’s safety, please list individuals that have permission to pick-up your child from the program. Those individuals listed must enter the building and sign the appropriate form before the child/children are released.  Our staff will not allow your child to leave the premises with an individual unless they are indicated on the list. Individuals must be 18 years old to sign-out your child. Additionally, your child will only be released to people that have been identified and who have appropriate picture identification.

*Please notify staff if you have a court ordered document preventing an individual from picking up your child

My child CAN/CANNOT be released to: Please place an asterisk (*) next to CANNOT.

TIME LIMIT & RIGHTS TO REVOKE AUTHORIZATION:

I understand that this authorization is valid for one year from the date of its signing or until the child is no longer enrolled in the program.  I may revoke this authorization at any time by notifying the Program Manager in writing.  I also understand that by signing this release, I am authorizing First State Community Action Agency, Inc. to verbally consult/communicate with the above listed individuals until enrollment is no longer in effect.

I do hereby consent to authorize First State Community Action Agency, Inc. to obtain information from the below listed school regarding my child.  Information to be obtained includes:

• IEP Records
• Report Cards
• Attendance Records
• Discipline/Behavior Records

I understand that any/all information gathered is prohibited from re-disclosure and is solely for the purpose of assisting in evaluation, monitoring, reporting and program implementation.

Time Limit & Rights to Revoke Authorization:

I understand that this authorization is valid for one year from the date of its signing or until the child is no longer enrolled in the program and I may revoke this authorization at any time by notifying the Program Manager in writing.  I aslo understand that by signing this release below, I am authorizing First State Community Action Agency, Inc. to verbally consult/communicate with the above listed organization until enrollment is no longer in effect.

To maintain enrollment in the program, youth must display the following behaviors and follow the directions and rules of the Staff at First State Community Action Agency's After School Programs.

• Respect the Staff and peers.
• NO fighting, name calling, bullying or use of profanity.
• Be polite and use good manners.
• NO running in the school/community center.
• Respect the property of the school/community center.
• Stay in designated areas at all times.  Must have permission for the bathroom/water breaks.
• NO use of electronics i.e. cell phones, IPods, video games, etc.  The same rules apply as they do during regular school hours.  First State CAA will not be held responsible for broken or stolen items.  (Please read the liability waiver.)

If Behavior or Discipline Problems Occur:

• Staff will speak with the student to work through the problem.
• Staff will write an incident report and submit it to the Program Coordinator/Manager.
• Parent(s) will be notified of the incident at the time of pick up.
• Parent(s) may be called to pick up their child in the event he/she is out of control.
• Child may be suspended from the program for excessive or persistent misbehavior issues.
• Program Coordinator/Manager may ask to meet with the child's parent(s) to discuss alternatives.
• Parent(s) may contact Program Manager/Coordinator with any questions or concerns regarding the child.

I have read and reveiwed the Discipline Policy with my child(ren) and fully understand that he/she must be compliant with the rules to remain in the Program.

Health Insurance: I understand that if emergency medical care is necessary and I cannot be reached, I authorize First State C.A.A. to act in my behalf in granting permission for my child to receive emergency medical treatment. Parents are responsible for all expenses incurred as the result of medical treatment.

I do hereby consent to authorize First State Community Action Agency, Inc. to obtain information from the below listed school regarding my child.  Information to be obtained includes:

• IEP Records
• Report Cards
• Attendance Records
• Discipline/Behavior Records

I understand that any/all information gathered is prohibited from re-disclosure and is solely for the purpose of assisting in evaluation, monitoring, reporting and program implementation.

Time Limit & Rights to Revoke Authorization:

I understand that this authorization is valid for one year from the date of its signing or until the child is no longer enrolled in the program and I may revoke this authorization at any time by notifying the Program Manager in writing.  I aslo understand that by signing this release below, I am authorizing First State Community Action Agency, Inc. to verbally consult/communicate with the above listed organization until enrollment is no longer in effect.

Health Insurance:  I understand that if emergency medical care is necessary and I cannot be reached, I authorize First State C.A.A. to act in my behalf in granting permission for my child to receive emergency medical treatment. Parents are responsible for all expenses incurred as the result of medical treatment.

I do hereby consent to authorize First State Community Action Agency, Inc. to obtain information from the below listed school regarding my child.  Information to be obtained includes:

• IEP Records
• Report Cards
• Attendance Records
• Discipline/Behavior Records

I understand that any/all information gathered is prohibited from re-disclosure and is solely for the purpose of assisting in evaluation, monitoring, reporting and program implementation.

Time Limit & Rights to Revoke Authorization:

I understand that this authorization is valid for one year from the date of its signing or until the child is no longer enrolled in the program and I may revoke this authorization at any time by notifying the Program Manager in writing.  I aslo understand that by signing this release below, I am authorizing First State Community Action Agency, Inc. to verbally consult/communicate with the above listed organization until enrollment is no longer in effect.

Health Insurance: I understand that if emergency medical care is necessary and I cannot be reached, I authorize First State C.A.A. to act in my behalf in granting permission for my child to receive emergency medical treatment. Parents are responsible for all expenses incurred as the result of medical treatment.

I do hereby consent to authorize First State Community Action Agency, Inc. to obtain information from the below listed school regarding my child.  Information to be obtained includes:

• IEP Records
• Report Cards
• Attendance Records
• Discipline/Behavior Records

I understand that any/all information gathered is prohibited from re-disclosure and is solely for the purpose of assisting in evaluation, monitoring, reporting and program implementation.

Time Limit & Rights to Revoke Authorization:

I understand that this authorization is valid for one year from the date of its signing or until the child is no longer enrolled in the program and I may revoke this authorization at any time by notifying the Program Manager in writing.  I aslo understand that by signing this release below, I am authorizing First State Community Action Agency, Inc. to verbally consult/communicate with the above listed organization until enrollment is no longer in effect.

I certify that the information I have provided is true and correct to the best of my knowledge.

Thank you!  If you have additional children to register, please contact us at asp@firststatecaa.org.

You may print a copy of your application for your records by clicking on the PREVIEW button.  Please hit SUBMIT when you are ready to submit your application.