ASES Registration 2020-2021 (042420)

 
Page 1 of 1
 
 Kid Connection Afterschool Program (ASES) 
Dear Parent/Guardians: Thank you for your interest in enrolling your child/ren Kid Connection Afterschool Program (ASES) administered through the Lake County Office of Education. Please complete the registration form below.

 
1.
*
 
   
School  
   
2.
*
 
      
Child     
Child     
Child     
   
3.
 
      
Child     
Child     
   
4.
 
      
Child     
Child     
   
5.
 


   
6.
*
 
    
Student   
Student   
   
7.
*
 
       
Mother/Guardian      
Father/Guardian      
   
8.
*
 
    
Responsible Person   
   
9.
CHILDREN WILL NOT BE RELEASED TO INDIVIDUALS NOT LISTED ON THIS FORM. Please keep this information updated.
 
      
Person     
Person     
Person     
   
10.
I verify that the information provided about the child/ren is complete and accurate. I understand that reasonable measures will be taken to safeguard the health and safety of all participants and that I will be notified as soon as possible in the case of an emergency. In the event of an emergency, if I cannot be reached, I hereby authorize transportation to a medical facility at my expense, to provide the necessary emergency medical treatment for my child/ren. I understand that neither my child's elementary school nor the Lake County Office of Education provide coverage.
 
     
Child    
Child    
Child    
   
11.
 
   
Child  
Child  
Child  
   
12.
*
Please click all that apply.
            
  
   
13.
*
I understand that parent fees are used as a match. THE MAXIMUM FAMILY FEE WILL BE $100.00 PER MONTH.
 
   
14.
(Please base your amount on the information listed next to your income level in the previous question.)
 
   
15.
*
All payments must be received on or before the 5th of each month. Please see the Parent Handbook for more information on monthly payments.
 
*
All payments must be received on or before the 5th of each month. Please see the Parent Handbook for more information on monthly payments.
    
   
16.
*
The Lake County Office of Education policy regarding District and School websites requires parental permission be acquired prior to use of any student image or likeness. Such use includes the display, distribution, publication, transmission, or use of photographs, images, artwork, written compositions, and/or video taken of student(s) for use in material that includes, but may not be limited to, printed materials, websites and social media. Parental consent is requested for your student to be photographed/videotaped during the school year.
 
*
The Lake County Office of Education policy regarding District and School websites requires parental permission be acquired prior to use of any student image or likeness. Such use includes the display, distribution, publication, transmission, or use of photographs, images, artwork, written compositions, and/or video taken of student(s) for use in material that includes, but may not be limited to, printed materials, websites and social media. Parental consent is requested for your student to be photographed/videotaped during the school year.
    
   
17.
For the safety and well-being of all students and staff, we need the cooperation of everyone in order to encourage positive behavior. I will read and agree to the Behavior Agreement in the Parent Handbook.
 
For the safety and well-being of all students and staff, we need the cooperation of everyone in order to encourage positive behavior. I will read and agree to the Behavior Agreement in the Parent Handbook.    
   
18.
I understand that my child must maintain at least 85% monthly attendance in order to remain in the ASES Program. I understand that my child must attend the ASES Program each day and stay until 6:00 P.M or as stated in the "Early Release Student Information" form.
 
I understand that my child must maintain at least 85% monthly attendance in order to remain in the ASES Program. I understand that my child must attend the ASES Program each day and stay until 6:00 P.M or as stated in the "Early Release Student Information" form.    
   
19.
A nutritious snack will be provided to students during the program. Please list all known food allergies.
 
   
20.
Nondiscrimination- In accordance with the Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
 
  
  
  
  
  
  
   
 
 
 
 Done  Save  Cancel