After-School Application

After-School Application
Dear Parents and Guardians,

Thank you for your interest in the After-School Program for Kindergarten through 6th grade at John 3:16 Mission Family and Youth Center. After School is a yearlong program that coincides with the days Tulsa Public Schools are in session. This school year the After-School Program will begin on August 20, 2024 and will end the last day of TPS. Students who are entering Kindergarten through 6th grade who meet the requirements of the student profile (see pg. 2) are eligible to apply. If accepted, your child will need to attend every day, Monday through Friday from the time they get out of school until 5:30pm.

The After-School Program is completely Christ-centered. Everything we do will focus on introducing your child to Christ and developing his/her relationship with our Savior. If accepted, your child will participate in the following activities: homework assistance, Bible lessons, memorizing Bible verses, praise and worship, Creative Arts, discipleship classes, and monthly field trips. An afternoon snack will be provided to each child as soon as they arrive at the mission.

Please take the time to fill out the information accurately and completely in the attached application. A separate application must be filled out for each child you wish to enroll in our After-School programming. Our enrollment is limited, so we ask that you carefully fill out the entire application and return it as soon as possible. The deadline for all applications is Friday, August 09, 2024, at 4pm. Incomplete and/or late applications will not be considered. You will be informed by phone by August 14, 2024 or sooner, as to whether your child has been accepted. For those children accepted into the program, there will be a mandatory parent meeting at the Family and Youth Center on Monday, August 19th, 2024, at 5:30pm to go over additional information regarding the After-School program.

If you have any questions regarding the After-School Program or the application process, please do not hesitate to call 918-592-1186 or email Grace Sifuentes at gperron@john316mission.org For Youth in 5th -HS please call 918.592.1186 or email Pastor Savage: vsavage@john316mission.org

PLEASE READ

STUDENT PROFILE

Our desire at the John 3:16 Mission Family and Youth Center is to provide the best possible experience for individuals involved with any of our programs. However, there are a handful of students unsuited for the John 3:16 Mission Family and Youth Center programs because of the highly structured environment and the limited time we have to work with the students. PLEASE BE AWARE that anyone who applies for enrollment in Mission programming and/or comes to the John 3:16 Mission Family and Youth Center with the following difficulties will be denied acceptance and/or sent home.
- Students on Psychotropic Drugs--(Behavior altering drugs such as Lithium). WE WILL NOT ACCEPT APPLICATIONS FOR STUDENTS ON PSYCHOTROPIC DRUGS. We are not qualified to handle them.
- Pregnant students--The John 3:16 Mission Family and Youth Center’s programs are very active and involve a large number of students. It exposes mother and child to unnecessary risk.
- We cannot accept students with pre-existing conditions such as Sickle Cell Disease, High Risk Diabetes, or Acute Asthmatics. We do not have the medical staff to monitor these students while they are at the John 3:16 Mission Family and Youth Center. The Director of the Family and Youth Center must clear all students with these conditions who attend programs at the Family and Youth Center before they will be able to participate in activities.
- Juvenile Delinquents/Wards of the State--Though we don’t exclude children with criminal records, we use extreme caution and discernment in allowing children with a criminal past who have a difficult time submitting to authority and following rules in a highly structured environment such as the John 3:16 Mission Family and Youth Center.
- Past students who have been a major discipline problem--students who didn’t respond to John 3:16 Mission Family and Youth Center discipline measures and/or were asked not to return to the Family and Youth Center.
- Any student that cannot be handled and/or is unresponsive to basic instruction.
- Any student who adversely affects the experience for other students, leaders, and staff will be sent home.

Church History
Does your family attend church?

OftenOccasionallyNo
Name of Church
Does your child attend Sunday school?

OftenOccasionallyNo
School History
Name Of School
Current Grade
Teacher's Name
Does your child receive any special education services or is he/she enrolled in an IEP?
What services/programs?
Has your child been diagosed with any learning disorders? Specify:
Has your child been placed in any gifted classes? Specify:
What is/are your childn's best subject(s)?
What subject(s) does your child struggle with?
Tell us why your child would benefit from this program. (financial, educational, spiritual, social reasons, etc.)
What other programs/activities is your child enrolled in during the school year? Will this conflict with the times/dates of the After-School program? This includes tutoring, church, and/or sporting activities. The more complete this list is and honest you are about these activities, the more likely we will be able to work with you.
What other information would be helpful for John 3:16 Mission Family and Youth Center staff and volunteers to know in order to best care for and teach your child this school year? Examples: social and behavioral history, recent changes at home, previous traumatic events, extracurricular activities, hobbies/interest, anything you feel would help us get to know your child.

Consent and Medical Release
I give permission for my child, child's name to be enrolled in the After-School Program provided through the John 3:16 Mission Family and Youth Center for the term: August 20,2024 - Last Day of TPS. I give the John 3:16 Mission staff and ministry workers permission to transport my child to and from the Family and Youth Center located at 2027 Martin Luther King Jr BLVD, Tulsa. If for any reason a medical emergency should occur, I authorize the John 3:16 Mission staff and ministry workers to secure medical care immediately. I understand that all expenses incurred in obtaining medical treatment will not be the responsibility of John 3:16 Mission. I understand that the involvement of my child in these programs is based on my child's active participation and responsible behavior at all activities. I have read and agree with the rules of conduct and student profile and I agree to work together with the John 3:16 Mission staff and ministry workers to enforce these rules. I understand that the failure of my child to follow these rules could result in the permanent dismissal from the program. I understand that photographs of my child participating in John 3:16 Mission activities may be used in Mission publications or displays.
Signature

Clear
Date

MonthDayYear
Date
Consent to Obtain Records
I give permission for the John 3:16 Mission personnel to secure any records, including confidential records, from my child’s school and/or teacher. This includes but is not limited to consultation with the school principal or my child’s teacher, health records, special education and remedial records, psychological profiles and behavior plans. These records will only be secured if needed to improve the instructional program plan for my child. I understand that John 3:16 Mission will keep all information concerning my child confidential.
Signature

Clear
Date

MonthDayYear
Date
Other Obligations
1. Be Supportive. I understand that the involvement of my child in this program is based on my child's active participation and responsible behavior at all times. I agree to be supportive of the John 3:16 Mission staff and ministry workers in providing neccessary discipline, reviewing notes sent home, signing and returning forms, and other reasonable support functions.
2. Be Available. I understand that I must be available during the day and be able to provide transportation for the pickup of my child if necessay at any point throughout the afternoon. It is crucial that we be able to reach you during the day in case of emergency or disciplinary problems requiring your assistance. I understand that should my contact information, i.e., address, phone numbers, and/or emergency contacts change during the time my child is enrolled in this program it is my responsibilty to update such information with the John 3:16 Mission staff as soon as possible.
3. Attendace and Pickup. I understand that this program is provided to my child free of cost and that other children are turned away. I will do my best to ensure that my child attends regulary so that he or she will not fall behind the other children. In the event that my child must miss a day, I will give as much prior notice to the John 3:16 Mission staff as possible. I also commit to dropping off and picking up my child on time every day the program is in session.
Signature

Clear
Date

MonthDayYear
Date

Rules of Conduct

Teaching Students to Reflect the Character of Christ in Their Lives
1. Students are expected to respect all John 3:16 Missoin Staff and ministry volunteers at all times.
2. Students are expected to respect each other with eheir words and actions. Fighting, bullying, or verbal abuse of another student will not be tolerated.
3. Students are expected to be obedient to all John 3:16 Mission staff and ministry volunteers; doing what they are told immediately, the first time they are told.
4. Students are expected to accept responsibility for their actions whether positive or negative and accept punishment for wrong choices and acitons.
5. Students are expected to speak honestly and use appropriate language at all times. Profanity, degrading comments towards others, and lying will not be tolerated.
6. Students are expected to ask permission to leave the group for any reason, including going to the restroom.
7. Sudents are expected to display self control with the building. Screaming, running in hallways, and pushing and shoving other students will nto be tolerated.
8. Students are expected to respect the facilities and clean up after themselves at all times. Destruction of Mission property will not be tolerated.
9. Students are expected to complete all assigned classroom work and participate in all classroom and ministry activities.
10. Students are expected to attend After-School programming every day that it is in session, from August 20, 2024 to Last Day of TPS. Students with an excessive amount of unexcused absences may face the possibility of dismissal from the program and will be ineligible for enrollement the next year.
Parents, please review these rules wtih your children. By signing below you agree that you have reviewed the rules of conduct, consent that they are reasonable and agree that you will work with the John 3:16 Mission staff and ministry volunteers to ensure that these rules are upheld by your children. Unsigned applications will not be considered.

Children, by signing below, you agree that you have reviewed the rules of conduct with your parents and will abide by these rules for the entiretly of your enrollment int the After-School program at John 3:16 Mission. Unsigned applications will not be considered.
Parent Signature

Clear
Date

MonthDayYear
Date
Student Signature

Clear
Date

MonthDayYear
Date

Medical Authorizaiton Form

August 20,2024 - Last Day of TPS
Students Name

First NameLast Name
Type a question

MonthDayYear
Father's Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Mother's Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Guardian's Name

First NameLast Name
Phone Number
Please enter a valid phone number.
List 2 Emergency Contacts if parents/guardian cannont be reached

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Physican's Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Dentist Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Hospital Preference

First NameLast Name
Authorization for administration of non-perscription medication at John 3:16 Mission FYC event:

Medication

	Yes	No	Additional Instructions
Tylenol
Ibuprofen
Benadryl
Tums
Triple antibiotic cream (Neosporin)
Clamine Lotion
Cough Drops

Authorization/Consent for Medical Treatment: In the event my child becomes ill or injured at the After-School Program or during a mission related activity or trip, the John 3:16 Mission is authorized to take one or more of the following actions: a) provide first aid; b) release my child to any of the people listed above; c) take my child to the physician or call the physician indicated; or d) take my child to a hospital and/or give consent for emergency care.
Signature

Clear

After-School Application

Child's Information

Parent's Information

Emergency Contact

Others In the Family

Church History

School History

Consent and Medical Release

Consent to Obtain Records

Other Obligations

Rules of Conduct

Medical Authorizaiton Form

Authorization for administration of non-perscription medication at John 3:16 Mission FYC event:

Student Health History

Check any of the following special health concerns our child has and provide appropriate explanations: