• 21st CCLC Afterschool Program Student Application

    2300 Courtland Drive - Sanford, NC - 919-774-9462 - www.pdypay.com

  • Academic School Year: 2026-2027

    Please complete every space or write N/A for Not Applicable

  • Student Information:

    Please complete the following information about your child. One child per application.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Male/Female*
  • Race:*

  • Parent/Guardian Information (PRIMARY)

    Please complete the following information about your child.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is the household's primary or preferred language?*

  • Parent/Guardian Information (SECONDARY)

    Please complete the following information about your child.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Persons (Must be at least 16 or older) authorized to pick up child other than parent(s):

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Please Note:

    List ANY AND ALL medications, allergies, or special needs for your child.

  • Emergency Care Information:

    Please complete the following information below in the event an of emergency
  • Format: (000) 000-0000.

  • If Parent/Guardian cannot be reached, call:

  • Format: (000) 000-0000.
  • I agree that the PAY 21st CCLC Afterschool Programs Director or Coordinator may authorize the physician of his/her choice to provide emergency care in the event that neither I nor a family physician can be contacted immediately.*

  • 21st Century Community Learning Center Medical Form

    The purpose of this form is to provide PAY Administration and Staff with pertinent information, which will help to serve the needs of your child and the Afterschool Program.
  • Does your child have any food or medical allergies?*
  • Is your child currently on a special diet?*
  • Has your child had any operations or serious injuries that required hospitalization?*
  • Does your child have any special health conditions: (ex: diabetes, asthma, occurring infections, skin conditions, etc...)?*
  • Does your child wear additional appliances? (ex: glasses, contacts, earplugs, etc...)?*
  • Is this an ongoing medication?*
  • I do hereby agree that I have provided the necessary information that is needed for my child's medical safety at PAY Afterschool. I hereby agree to keep Administration and Staff informed and updated with any/all medical changes for my child. Failure to provide and disclose pertinent information about your child for Program Use could affect your child's participation in the program activities.*
  • Image field 100

  • Parent Request for Transportation to Afterschool Enrichment Program and Release for Academic Information

    Incomplete forms will be returned to Afterschool Program Enrichment Contact
  • Select your child's school:*

  • Please list the student's name as it appears on the student records at school.

    Forms that have incomplete and/or inaccurate information may delay transportation service.
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • By signing the form, I give permission for my child to attend PAY Afterschool Enrichment Program.  I understand that Lee County Schools and Rising Leaders Academy will use their school buses to transport my child to the afterschool program. I understand that Ascend Leadership Academy and Lee Christian School students will be picked up daily by PAY Afterschool Transportation.  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 their regularly scheduled school route from school to home.  This will continue until the school receives notification to terminate transportation services 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.

  • Please answer the following statement above.*
  • Image field 101

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

  • Date Received
     - -
    2 digit month, 2 digit day, 4 digit year

  • Parent Authorization Form

    Please carefully read the following, initial where indicated and contest 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:

  • I give my permission for my child to participate in program activities.  Please list any possible exclusions:*

  • Emergency Procedures

  • In case of emergency, I authorize the program staff to directly contact the persons named on this enrollment form.  If the parent, guardian or authorized person cannot be contacted, the program’s employees are authorized to take necessary action for the health and welfare of my child.  I agree that I am solely responsible for payment of all costs resulting from emergency medical treatment and/or ambulance services.*

  • Transportation

  • I give permission for my child to participate in all field trips where he/she will be under the supervision of the 21st Century faculty and staff while they are physically away from the site.*

  • Sign In/Out Procedures and Responsibilities

  • I agree to follow the sign in/out procedures.  I understand that the program is not responsible for children that are not properly signed in. (Due to COVID, please pull up to the front door and remain in your car until your child is dismissed from their classroom. The 21st CCLC does not allow children to sign themselves in/out.  If your child rides the van in the afternoon, there has to be an adult home with the child during drop off.*

  • Student Records Update

  • I understand that I must keep my child’s records up to date with the most current and updated home and work telephone numbers of both myself and those authorized above to pick up my children on my behalf.*

  • Media Release

  • I hereby consent to and authorize the use and reproduction by the 21st Century Afterschool Learning Center (PAY) of all photographs and /or other audiovisual materials taken of me and my child for promotional printed material, educational activities, exhibitions, or for any other use for the benefit of the program. By authorizing this release, the community instantly becomes aware of what your child/children are experiencing in our afterschool environment.*

  • Health and Safety Procedures

  • I hereby consent to my child wearing a mask, at the discretion of the Administrative Staff, while on the premises of PAY Afterschool Program.  I know and understand that for full safety of students, staff and the facility, a mask, when deemed necessary, must be worn.  If my child cannot wear a mask, I will provide doctor or physical verification (Program Directors must approve before the child can attend). PDY/PAY plans to follow the guidelines implemented within Lee County Schools.*
  • Today's Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Parent Handbook and Acceptance Use Policy

  • 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. 

  • Please answer.*
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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 2026-2027 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. ****

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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