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GORDON COUNTY SCHOOLS

AFTER SCHOOL PROGRAM STUDENT HANDBOOK

2019-2020

Dear Parent/Guardian,

This handbook outlines the policies and procedures followed by the Gordon County School System’s After School Program.  We appreciate you entrusting your child to our care.  Please read this handbook with your child before signing and submitting the program registration forms so we may know you fully understand our policies.  The term “parent” within this handbook shall encompass “parent(s)” or “legal guardian(s)”.  It is the sole duty and responsibility of the parent or guardian to update contact information should it change and to notify the After School Program’s Site Director should eligibility change. 

The Registration Form and Liability Waiver/Medical Release Form must be signed and submitted to the ASP Site Director at your child’s school before he/she may begin participating in the After School Program.  Also, the “Time to Behave”Discipline Contractmust be signed and submitted to the After School Program Site Director.  We recommend you keep this handbook in a convenient place for future reference.  We look forward to serving you and your family in the months ahead.

Sincerely,

Teresa Taylor, ASP Coordinator

Stephanie Gilbert, Community Ed. Coordinator

GENERAL INFORMATION

All Gordon County elementary schools offer the After School Child Care Program for the purpose of providing supervision to school-age children from the time school is dismissed until 6:00 p.m. each school day.  The programs are open to all children enrolled in Pre-K through fifth grade classes at the school the student is presently attending.  Gordon County Elementary Schools are peanut-free.

Each program strives to establish a safe and caring environment that allows for individual and social growth.  Children engage in activities that encourage creativity, social relationships, appropriate behavior, and a positive self-image.  Activities include study time, recreational activities, arts and crafts, and other enrichment activities. 

*Students of elementary teachers should attend the After School Program at his/her respective school to allow planning time in the afternoon.

Registration

The following items are to be signed and completed:

  • All Registration Forms
  • Time to Behave!Discipline Contract
  • Updated medical information and Medical Release Form
  • Proof of accident insurance (highly encouraged)
  • Emergency contact person(s) other than parents

*Please make sure the ASP Site Director receives any changes in contact information such as phone number(s), address, etc.

Communication

We work to maintain effective communications with all parties to ensure that quality care is given to children, and we encourage parents to offer suggestions and ideas that would enhance the program. To keep you informed, lesson plans, activities, and announcements are posted at the site.

Personal Property

Personal property such as toys, games, and jewelry should not be brought to the After School Program. Parents are responsible for securing book bags, lunchboxes, coats, etc. when picking up their child. We make every attempt to help children stay organized; however, we are not responsible for the loss of personal items.

Insurance Requirement (Highly Encouraged)

Children may not participate in the After School Program until they can demonstrate they are covered by accident insurance. Parents are responsible for accident insurance coverage for their child. Those who do not have insurance may apply at www.studentinsurance-KK.com.

Medication

Medication is not to be administered by After School Program Staff unless authorized. Arrangements for administering medications must be made through the school office prior to the child coming to the program. (Nurse’s Office is not accessible during ASP hours)

Illness

If a child becomes ill during his/her stay in the program, these procedures will be followed:

-  The site director will call the parent or guardian and discuss the child’s symptoms.

-  If symptoms persist or worsen, the parent will be called to pick up the child.

-  No child will be admitted or kept in the program if he/she has a temperature exceeding 99.3o Fahrenheit.

Safety Procedures

In establishing appropriate student safety plans/protocols for the After School Program, schools should develop and implement procedures according to the following guidelines:

1)  Protocol outlined in the School Safety Plan should be utilized, especially protocols for dealing with the following:

a. Incidents: Lock-Down or Evacuation of the building
b. Intruder, Suspicious Person
c. Missing Student/Kidnapping
d. Injuries to Staff or Students
e. First Aid Procedures

2)  Additionally, the following protocol for dealing with the following situations should be developed and implemented:

a. Dealing with inclement weather
b. Notification of parents following injury to student
c. Release of student to parents/others (check out procedures)
d. Procedures for handling situations that involve bodily fluid
e. Filing an incident report
f. Playground safety procedures

*Conduct an emergency evacuation drill and severe weather drill at least once each semester (as early in the semester as possible). Site Directors are to notify the ASP Coordinator as to the dates/times planned for drills.

When a child is injured in the ASP:

- Follow first aid procedures immediately
- Contact emergency personnel, if warranted
- Notify ASP Site Director or certified person on duty

Immediately

- Notify parents immediately
- Notify principal immediately
- Notify school nurse (if on duty)
- Notify Teresa Taylor
- A student incident report must be filled out explaining the nature of the incident.

Sign-Out Policy (After School)

In the interest of safety and security, all children must be signed out daily by parents, guardians, or someone listed on the registration form with complete name. A driver’s license will be requested as identification from those persons picking up a child.

*Failure to sign out a child will be considered a serious rule infraction.

In addition, it is a parent’s duty and responsibility at all times to provide a fit, responsible, and unimpaired person to pick up the child from the After School Program. By placing the child in the program, the parent agrees and certifies that any person who picks up the child shall be fit, responsible, unimpaired and shall not endanger the child. Law enforcement officials shall be notified if anyone impaired by drugs, alcohol, or any other reason attempts to pick up a child.

Early Release

The After School Program will be fully operational until 6:00 p.m. when early release days are scheduled.

After School Child Care Program Fees for 2019–2020

Registration Fee:
A $25.00 registration fee will be charged for the first child to attend the Gordon County School After School Program. Each additional child will be $12.50. A family with four or more children will pay no more than $50.00 total registration fees.
The registration fee for new enrollees after January 1, will be $12.50 for the first child and $6.25 for each additional child, a family with four or more children will pay no more than $25.00 total registration fees.

*A $25.00 registration fee will be charged for a drop-in student upon the second visit.

Cost Per Week: $25.00

*Additional Child $20.00/Week (Per Family)

**Drop-In Fee $5.00 per day

*** The second drop in will require a registration fee and a full weekly payment

***Shortened school weeks will be pro-rated.

​Payment Fee

After School Program fees are to be pre-paid weekly on the first day of each week that a child attends the program. In the event that the pre-payments are not made in full, and in advance, the child will not be allowed to attend. Charges for “drop-in” students must be paid when the student is picked up. Students will not be allowed as a “drop-in” in the ASP if there is an outstanding balance.

Late Payment Fee

Charges will be imposed for late pick-up beginning at 6:01 p.m. The charge will be $1.00 PER MINUTE PER CHILD and must be paid at the time and on the day the child is picked up. Frequent abuse of pick- up will result in the student being removed.

Refunds

Refunds will be issued by the Central Office two times per year: January and May.

Transfer of Overdue Charges
Overdue charges will transfer to the student and will follow him/her throughout their school career. Students with remaining ASP overdue charges will be prohibited from participating in graduation services.

I understand that it is my responsibility to prepay After School Program (ASP) weekly charges on the first day of each week for my child/children to attend the program.

Parent/Guardian Signature

Date: August 20, 2019

Discipline/Dismissal/Suspension

Time to Behave!

Because children are entitled to a pleasant and harmonious environment, we cannot serve those who display chronically disruptive behavior. Chronically disruptive behavior is defined as verbal or physical activity which may include, but is not limited to, behavior that requires constant attention from the staff, inflicts physical or emotional harm on other children, abuses the staff, and involves willful destruction of property, or that which ignores or disobeys program rules.

-  If a child cannot adjust to the rules of the program and behave appropriately, he/she may be dismissed or suspended from the program.

-  Reasonable efforts will be made to assist the child in making needed adjustments.

-  Disruptive behavior will be dealt with by presiding ASP staff in a fair and consistent manner.

This includes:

1) First Offense: Verbal Warning

2) Second Offense: The student will be separated from the group and taken to an area where he/she will not be allowed to participate in activities for the remainder of the class time. Parents will be notified.

3) Third Offense: Student will be suspended from the After School Program for a period of one week.

4) Following re-admission to the program, if the student again receives disciplinary action the student may be permanently dismissed from attending the After School Program.

Not withstanding the foregoing, the After School Program’s Site Director or School Principal may at any time, at his or her sole discretion, permanently dismiss a student from the After School Childcare Program should a student’s conduct merit dismissal. The Parent and/or Guardian must sign and date the “Time to Behave!” contract during the registration process in order for his/her child to attend Gordon County’s After School Program.

I have read and understand the discipline rules that must be adhered to by my child/children in order to attend the After School Program.

Parent/Guardian Signature

Date: August 20, 2019

PARENTS AUTHORIZATION & LIABILITY WAIVER

In consideration of Gordon County Schools granting my child the privilege of attending the After School Program, I/my child do agree to waive and hereby release any and all rights which I/my child may now or hereafter have against Gordon County Schools, it’s representatives, agents, or assigns for any injury or accident which I/my child regret to identify and hold harmless Gordon County Schools, its representatives, or assign from any claim, action, cause of action on account or arising out of or in connection with I/my child’s participation in the said course. I/my child hereby acknowledge that I/my child have been advised of the potential dangers inherent in the aforesaid activity, and I/my child fully understand those potential dangers. I am the parent or legal guardian of the above named child. 

Signed this day: August 20, 2019

Parent/Guardian Signature

Medical Release Form

I understand that my child is not allowed to have in his/her possession or administer to himself/herself any medication while at the ASP. The ASP must have medication for a life threatening condition. The ASP does not have access to the nurse’s office. I authorize Gordon County Schools and their agents as appropriate to issue the checked medicines as needed for a routine medical condition. If any further treatment is needed, I understand that I/we will be notified immediately.

Parent/Guardian Signature

*Please sign and submit the Liability Waiver and Medical Release Form, Registration Form, and “Time To Behave” Discipline Contract to your child’s After School Program Site Director.

We would like to thank each and every parent for sharing your children with us this year!

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Gordon County School System After School Program
REGISTRATION FORM

Program Requirements: A completed Registration Form must be received by the ASP Site Director or the school office two (2) days prior to the child attending the ASP.
*It is the sole duty and responsibility of the parent(s) or guardian(s) to update information/data for this registration should circumstances or eligibility change.

Tuition is due for students participating in the After School Program on the first day of each week


Grade: *

School: *

Homeroom Teacher: *

Check which parent should be called first in case of an emergency:


Employer: *

Phone (ext): *

Check below the type of participation desired for your child to participate in the After School Program. If part-time, please specify day(s) your child will attend each week. Advance notice of changes is required for part-time participants. 

Monday
Tuesday
Wednesday
Thursday
Friday

Highly Recommended For All ASP Students: 

(A copy of your insurance card or verification.) 


My child has Accident Insurance with:

Please list all allergies or medical problems:

Please check medications that may be given to your child by the ASP Child Care workers if needed: 

Band-Aids
Latex Gloves
Neosporin
Ice Packs
Hydrocortisone

Name of Parents:

Address:

City:

State:

Mother's Work:

Father's Work:

The ASP staff wants to insure a safe and enjoyable experience for your child. Please help us by:

  1. Signing out your child when you come to pick him/her up.

  2. Supplying us in writing the names of the person(s) who may pick up your child.

The ASP staff will release a child only to the parent/guardian who enrolled the child or the person(s) specifically authorized below (photo identification is required): 


1. Name:

Relationship:

Address:

Phone:

2. Name

Relationship:

Address:

Phone:

3. Name:

Relationship:

Address:

Phone:

4. Name:

Relationship:

Address:

Phone:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Gordon County School System After School Program
REGISTRATION FORM

Program Requirements: A completed Registration Form must be received by the ASP Site Director or the school office two (2) days prior to the child attending the ASP.
*It is the sole duty and responsibility of the parent(s) or guardian(s) to update information/data for this registration should circumstances or eligibility change.

Tuition is due for students participating in the After School Program on the first day of each week


Grade: *

School: *

Homeroom Teacher: *

Check which parent should be called first in case of an emergency:


Employer: *

Phone (ext): *

Check below the type of participation desired for your child to participate in the After School Program. If part-time, please specify day(s) your child will attend each week. Advance notice of changes is required for part-time participants. 

Monday
Tuesday
Wednesday
Thursday
Friday

Highly Recommended For All ASP Students: 

(A copy of your insurance card or verification.) 


My child has Accident Insurance with:

Please list all allergies or medical problems:

Please check medications that may be given to your child by the ASP Child Care workers if needed: 

Band-Aids
Latex Gloves
Neosporin
Ice Packs
Hydrocortisone

Name of Parents:

Address:

City:

State:

Mother's Work:

Father's Work:

The ASP staff wants to insure a safe and enjoyable experience for your child. Please help us by:

  1. Signing out your child when you come to pick him/her up.

  2. Supplying us in writing the names of the person(s) who may pick up your child.

The ASP staff will release a child only to the parent/guardian who enrolled the child or the person(s) specifically authorized below (photo identification is required): 


1. Name:

Relationship:

Address:

Phone:

2. Name

Relationship:

Address:

Phone:

3. Name:

Relationship:

Address:

Phone:

4. Name:

Relationship:

Address:

Phone:
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Gordon County School System After School Program
REGISTRATION FORM

Program Requirements: A completed Registration Form must be received by the ASP Site Director or the school office two (2) days prior to the child attending the ASP.
*It is the sole duty and responsibility of the parent(s) or guardian(s) to update information/data for this registration should circumstances or eligibility change.

Tuition is due for students participating in the After School Program on the first day of each week


Grade: *

School: *

Homeroom Teacher: *

Check which parent should be called first in case of an emergency:


Employer: *

Phone (ext): *

Check below the type of participation desired for your child to participate in the After School Program. If part-time, please specify day(s) your child will attend each week. Advance notice of changes is required for part-time participants. 

Monday
Tuesday
Wednesday
Thursday
Friday

Highly Recommended For All ASP Students: 

(A copy of your insurance card or verification.) 


My child has Accident Insurance with:

Please list all allergies or medical problems:

Please check medications that may be given to your child by the ASP Child Care workers if needed: 

Band-Aids
Latex Gloves
Neosporin
Ice Packs
Hydrocortisone

Name of Parents:

Address:

City:

State:

Mother's Work:

Father's Work:

The ASP staff wants to insure a safe and enjoyable experience for your child. Please help us by:

  1. Signing out your child when you come to pick him/her up.

  2. Supplying us in writing the names of the person(s) who may pick up your child.

The ASP staff will release a child only to the parent/guardian who enrolled the child or the person(s) specifically authorized below (photo identification is required): 


1. Name:

Relationship:

Address:

Phone:

2. Name

Relationship:

Address:

Phone:

3. Name:

Relationship:

Address:

Phone:

4. Name:

Relationship:

Address:

Phone:
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Gordon County School System After School Program
REGISTRATION FORM

Program Requirements: A completed Registration Form must be received by the ASP Site Director or the school office two (2) days prior to the child attending the ASP.
*It is the sole duty and responsibility of the parent(s) or guardian(s) to update information/data for this registration should circumstances or eligibility change.

Tuition is due for students participating in the After School Program on the first day of each week


Grade: *

School: *

Homeroom Teacher: *

Check which parent should be called first in case of an emergency:


Employer: *

Phone (ext): *

Check below the type of participation desired for your child to participate in the After School Program. If part-time, please specify day(s) your child will attend each week. Advance notice of changes is required for part-time participants. 

Monday
Tuesday
Wednesday
Thursday
Friday

Highly Recommended For All ASP Students: 

(A copy of your insurance card or verification.) 


My child has Accident Insurance with:

Please list all allergies or medical problems:

Please check medications that may be given to your child by the ASP Child Care workers if needed: 

Band-Aids
Latex Gloves
Neosporin
Ice Packs
Hydrocortisone

Name of Parents:

Address:

City:

State:

Mother's Work:

Father's Work:

The ASP staff wants to insure a safe and enjoyable experience for your child. Please help us by:

  1. Signing out your child when you come to pick him/her up.

  2. Supplying us in writing the names of the person(s) who may pick up your child.

The ASP staff will release a child only to the parent/guardian who enrolled the child or the person(s) specifically authorized below (photo identification is required): 


1. Name:

Relationship:

Address:

Phone:

2. Name

Relationship:

Address:

Phone:

3. Name:

Relationship:

Address:

Phone:

4. Name:

Relationship:

Address:

Phone:
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Gordon County School System After School Program
REGISTRATION FORM

Program Requirements: A completed Registration Form must be received by the ASP Site Director or the school office two (2) days prior to the child attending the ASP.
*It is the sole duty and responsibility of the parent(s) or guardian(s) to update information/data for this registration should circumstances or eligibility change.

Tuition is due for students participating in the After School Program on the first day of each week


Grade: *

School: *

Homeroom Teacher: *

Check which parent should be called first in case of an emergency:


Employer: *

Phone (ext): *

Check below the type of participation desired for your child to participate in the After School Program. If part-time, please specify day(s) your child will attend each week. Advance notice of changes is required for part-time participants. 

Monday
Tuesday
Wednesday
Thursday
Friday

Highly Recommended For All ASP Students: 

(A copy of your insurance card or verification.) 


My child has Accident Insurance with:

Please list all allergies or medical problems:

Please check medications that may be given to your child by the ASP Child Care workers if needed: 

Band-Aids
Latex Gloves
Neosporin
Ice Packs
Hydrocortisone

Name of Parents:

Address:

City:

State:

Mother's Work:

Father's Work:

The ASP staff wants to insure a safe and enjoyable experience for your child. Please help us by:

  1. Signing out your child when you come to pick him/her up.

  2. Supplying us in writing the names of the person(s) who may pick up your child.

The ASP staff will release a child only to the parent/guardian who enrolled the child or the person(s) specifically authorized below (photo identification is required): 


1. Name:

Relationship:

Address:

Phone:

2. Name

Relationship:

Address:

Phone:

3. Name:

Relationship:

Address:

Phone:

4. Name:

Relationship:

Address:

Phone:
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Gordon County School System After School Program
REGISTRATION FORM

Program Requirements: A completed Registration Form must be received by the ASP Site Director or the school office two (2) days prior to the child attending the ASP.
*It is the sole duty and responsibility of the parent(s) or guardian(s) to update information/data for this registration should circumstances or eligibility change.

Tuition is due for students participating in the After School Program on the first day of each week


Grade: *

School: *

Homeroom Teacher: *

Check which parent should be called first in case of an emergency:


Employer: *

Phone (ext): *

Check below the type of participation desired for your child to participate in the After School Program. If part-time, please specify day(s) your child will attend each week. Advance notice of changes is required for part-time participants. 

Monday
Tuesday
Wednesday
Thursday
Friday

Highly Recommended For All ASP Students: 

(A copy of your insurance card or verification.) 


My child has Accident Insurance with:

Please list all allergies or medical problems:

Please check medications that may be given to your child by the ASP Child Care workers if needed: 

Band-Aids
Latex Gloves
Neosporin
Ice Packs
Hydrocortisone

Name of Parents:

Address:

City:

State:

Mother's Work:

Father's Work:

The ASP staff wants to insure a safe and enjoyable experience for your child. Please help us by:

  1. Signing out your child when you come to pick him/her up.

  2. Supplying us in writing the names of the person(s) who may pick up your child.

The ASP staff will release a child only to the parent/guardian who enrolled the child or the person(s) specifically authorized below (photo identification is required): 


1. Name:

Relationship:

Address:

Phone:

2. Name

Relationship:

Address:

Phone:

3. Name:

Relationship:

Address:

Phone:

4. Name:

Relationship:

Address:

Phone:
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Gordon County School System After School Program
REGISTRATION FORM

Program Requirements: A completed Registration Form must be received by the ASP Site Director or the school office two (2) days prior to the child attending the ASP.
*It is the sole duty and responsibility of the parent(s) or guardian(s) to update information/data for this registration should circumstances or eligibility change.

Tuition is due for students participating in the After School Program on the first day of each week


Grade: *

School: *

Homeroom Teacher: *

Check which parent should be called first in case of an emergency:


Employer: *

Phone (ext): *

Check below the type of participation desired for your child to participate in the After School Program. If part-time, please specify day(s) your child will attend each week. Advance notice of changes is required for part-time participants. 

Monday
Tuesday
Wednesday
Thursday
Friday

Highly Recommended For All ASP Students: 

(A copy of your insurance card or verification.) 


My child has Accident Insurance with:

Please list all allergies or medical problems:

Please check medications that may be given to your child by the ASP Child Care workers if needed: 

Band-Aids
Latex Gloves
Neosporin
Ice Packs
Hydrocortisone

Name of Parents:

Address:

City:

State:

Mother's Work:

Father's Work:

The ASP staff wants to insure a safe and enjoyable experience for your child. Please help us by:

  1. Signing out your child when you come to pick him/her up.

  2. Supplying us in writing the names of the person(s) who may pick up your child.

The ASP staff will release a child only to the parent/guardian who enrolled the child or the person(s) specifically authorized below (photo identification is required): 


1. Name:

Relationship:

Address:

Phone:

2. Name

Relationship:

Address:

Phone:

3. Name:

Relationship:

Address:

Phone:

4. Name:

Relationship:

Address:

Phone:
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Gordon County School System After School Program
REGISTRATION FORM

Program Requirements: A completed Registration Form must be received by the ASP Site Director or the school office two (2) days prior to the child attending the ASP.
*It is the sole duty and responsibility of the parent(s) or guardian(s) to update information/data for this registration should circumstances or eligibility change.

Tuition is due for students participating in the After School Program on the first day of each week


Grade: *

School: *

Homeroom Teacher: *

Check which parent should be called first in case of an emergency:


Employer: *

Phone (ext): *

Check below the type of participation desired for your child to participate in the After School Program. If part-time, please specify day(s) your child will attend each week. Advance notice of changes is required for part-time participants. 

Monday
Tuesday
Wednesday
Thursday
Friday

Highly Recommended For All ASP Students: 

(A copy of your insurance card or verification.) 


My child has Accident Insurance with:

Please list all allergies or medical problems:

Please check medications that may be given to your child by the ASP Child Care workers if needed: 

Band-Aids
Latex Gloves
Neosporin
Ice Packs
Hydrocortisone

Name of Parents:

Address:

City:

State:

Mother's Work:

Father's Work:

The ASP staff wants to insure a safe and enjoyable experience for your child. Please help us by:

  1. Signing out your child when you come to pick him/her up.

  2. Supplying us in writing the names of the person(s) who may pick up your child.

The ASP staff will release a child only to the parent/guardian who enrolled the child or the person(s) specifically authorized below (photo identification is required): 


1. Name:

Relationship:

Address:

Phone:

2. Name

Relationship:

Address:

Phone:

3. Name:

Relationship:

Address:

Phone:

4. Name:

Relationship:

Address:

Phone:
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Gordon County School System After School Program
REGISTRATION FORM

Program Requirements: A completed Registration Form must be received by the ASP Site Director or the school office two (2) days prior to the child attending the ASP.
*It is the sole duty and responsibility of the parent(s) or guardian(s) to update information/data for this registration should circumstances or eligibility change.

Tuition is due for students participating in the After School Program on the first day of each week


Grade: *

School: *

Homeroom Teacher: *

Check which parent should be called first in case of an emergency:


Employer: *

Phone (ext): *

Check below the type of participation desired for your child to participate in the After School Program. If part-time, please specify day(s) your child will attend each week. Advance notice of changes is required for part-time participants. 

Monday
Tuesday
Wednesday
Thursday
Friday

Highly Recommended For All ASP Students: 

(A copy of your insurance card or verification.) 


My child has Accident Insurance with:

Please list all allergies or medical problems:

Please check medications that may be given to your child by the ASP Child Care workers if needed: 

Band-Aids
Latex Gloves
Neosporin
Ice Packs
Hydrocortisone

Name of Parents:

Address:

City:

State:

Mother's Work:

Father's Work:

The ASP staff wants to insure a safe and enjoyable experience for your child. Please help us by:

  1. Signing out your child when you come to pick him/her up.

  2. Supplying us in writing the names of the person(s) who may pick up your child.

The ASP staff will release a child only to the parent/guardian who enrolled the child or the person(s) specifically authorized below (photo identification is required): 


1. Name:

Relationship:

Address:

Phone:

2. Name

Relationship:

Address:

Phone:

3. Name:

Relationship:

Address:

Phone:

4. Name:

Relationship:

Address:

Phone:
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Gordon County School System After School Program
REGISTRATION FORM

Program Requirements: A completed Registration Form must be received by the ASP Site Director or the school office two (2) days prior to the child attending the ASP.
*It is the sole duty and responsibility of the parent(s) or guardian(s) to update information/data for this registration should circumstances or eligibility change.

Tuition is due for students participating in the After School Program on the first day of each week


Grade: *

School: *

Homeroom Teacher: *

Check which parent should be called first in case of an emergency:


Employer: *

Phone (ext): *

Check below the type of participation desired for your child to participate in the After School Program. If part-time, please specify day(s) your child will attend each week. Advance notice of changes is required for part-time participants. 

Monday
Tuesday
Wednesday
Thursday
Friday

Highly Recommended For All ASP Students: 

(A copy of your insurance card or verification.) 


My child has Accident Insurance with:

Please list all allergies or medical problems:

Please check medications that may be given to your child by the ASP Child Care workers if needed: 

Band-Aids
Latex Gloves
Neosporin
Ice Packs
Hydrocortisone

Name of Parents:

Address:

City:

State:

Mother's Work:

Father's Work:

The ASP staff wants to insure a safe and enjoyable experience for your child. Please help us by:

  1. Signing out your child when you come to pick him/her up.

  2. Supplying us in writing the names of the person(s) who may pick up your child.

The ASP staff will release a child only to the parent/guardian who enrolled the child or the person(s) specifically authorized below (photo identification is required): 


1. Name:

Relationship:

Address:

Phone:

2. Name

Relationship:

Address:

Phone:

3. Name:

Relationship:

Address:

Phone:

4. Name:

Relationship:

Address:

Phone:
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Gordon County School System After School Program
REGISTRATION FORM

Program Requirements: A completed Registration Form must be received by the ASP Site Director or the school office two (2) days prior to the child attending the ASP.
*It is the sole duty and responsibility of the parent(s) or guardian(s) to update information/data for this registration should circumstances or eligibility change.

Tuition is due for students participating in the After School Program on the first day of each week


Grade: *

School: *

Homeroom Teacher: *

Check which parent should be called first in case of an emergency:


Employer: *

Phone (ext): *

Check below the type of participation desired for your child to participate in the After School Program. If part-time, please specify day(s) your child will attend each week. Advance notice of changes is required for part-time participants. 

Monday
Tuesday
Wednesday
Thursday
Friday

Highly Recommended For All ASP Students: 

(A copy of your insurance card or verification.) 


My child has Accident Insurance with:

Please list all allergies or medical problems:

Please check medications that may be given to your child by the ASP Child Care workers if needed: 

Band-Aids
Latex Gloves
Neosporin
Ice Packs
Hydrocortisone

Name of Parents:

Address:

City:

State:

Mother's Work:

Father's Work:

The ASP staff wants to insure a safe and enjoyable experience for your child. Please help us by:

  1. Signing out your child when you come to pick him/her up.

  2. Supplying us in writing the names of the person(s) who may pick up your child.

The ASP staff will release a child only to the parent/guardian who enrolled the child or the person(s) specifically authorized below (photo identification is required): 


1. Name:

Relationship:

Address:

Phone:

2. Name

Relationship:

Address:

Phone:

3. Name:

Relationship:

Address:

Phone:

4. Name:

Relationship:

Address:

Phone:
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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