Enrollment Form and Emergency Medical Information Ridgewood High School and Middle School

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1 BEYOND THE BELL Afterschool Enrollment Form and Emergency Medical Information Ridgewood High School and Middle School [ Please be sure to fill out BOTH SIDES of this form ] Student DOB / / Grade Gender Address Parent/Guardian Phone Student Phone(if any) Does the Student have an IEP or a 504 Plan? Y N Are Parents Divorced/Separated? If yes, with whom does the student live? Is either parent deceased? If yes, which parent and when? If applicable, please list the name of the step-parent Mother/Guardian information Father/Guardian information Attendance Regular attendance in the afterschool program is strongly encouraged in order to get the most benefit. Students who attend 30 or more days are shown to improve in grades, math and reading proficiency, homework completion, class participation, and behavior issues. Please encourage your student to attend as often as possible for academic work, clubs, socialization, etc. Attendance Policy My student will attend the afterschool program s homework help on an as-needed basis, or attend club activities scheduled on different days. I do not wish to be contacted on days that he/she does not attend. Parent/Guardian Initials My student will attend the afterschool program every day that it is open, unless I have excused him/her with a note, phone call, etc. I wish to be contacted every day that he/she does not attend. Parent/Guardian Initials LIST THREE PERSONS WHO ARE AUTHIZED TO PICK UP THE STUDENT *Three people are the State required minimum; more can be listed on a separate sheet of paper.

2 My child MAY sign him/herself out. I understand that Beyond the Bell is not responsible for my child s safety or whereabouts after leaving the program. *Please select ONE sign-out option below. My child MAY NOT sign him/herself out. Only myself or an adult listed above will sign my child out each day he/she attends. DO NOT RELEASE The following people are not allowed to take my student (court papers required) *State Licensing requires that we have the following information for each student Preferred Physician Preferred Dentist Does student have any food, medication, or environmental allergies? If yes, please list and explain: BEYOND THE BELL HAS PERMISSION to secure emergency transportation for my student in the event of illness or injury. The emergency transportation service will determine the facility to which my child will be transported EMERGENCY MEDICAL AUTHIZATION BEYOND THE BELL DOES NOT HAVE PERMISSION to secure emergency transportation for my student in the event of illness or injury which requires emergency treatment. ACKNOWLEDGEMENT OF POLICIES & PROCEDURES I, the afterschool student, understand that the BEYOND THE BELL afterschool program is an extension of the school day and has the same high expectations for student success and behavior. I also understand that my participation in homework help, clubs, field trips, and other activities are based on my actions and attitude during afterschool and the regular school day. As a Ridgewood student and a BEYOND THE BELL enrollee I agree to respect my peers, afterschool staff, equipment and myself. Student Signature Date I, the parent or guardian, give my student permission to attend the BEYOND THE BELL afterschool program. I will read the parent handbook that describes the policies of the program. I will discuss that information with my student, specifically the behavior policy. I am aware of the possibility of receiving a gas voucher based on financial need and will request an application if I wish to receive gas vouchers. I understand that in order for my student to receive the maximum benefit from the program, afterschool staff will receive information from the student s regular classroom teachers as well as use information obtained from the Developmental Asset Survey (DAP) that the student will complete upon beginning the program. Y N My student has permission to access the Internet for educational purposes under supervision of the staff. Y N I give permission for my student s photograph to be taken during activities and used for program promotion. Y N I give permission for my student to watch suitable PG-13 movies. Parent/Guardian Signature Date

3 BEYOND THE BELL Afterschool Enrollment Form and Emergency Medical Information Grades K - 5 [ Please be sure to fill out BOTH SIDES of this form ] Student DOB / / Grade Gender Address Parent/Guardian Phone Student Phone(if any) Does the Student have an IEP or a 504 Plan? Y N Are Parents Divorced/Separated? If yes, with whom does the student live? Is either parent deceased? If yes, which parent and when? If applicable, please list the name of the step-parent Mother/Guardian information Father/Guardian information Attendance Regular attendance in the afterschool program is strongly encouraged in order to get the most benefit. Students who attend 30 or more days are shown to improve in grades, math and reading proficiency, homework completion, class participation, and behavior issues. Please encourage your student to attend as often as possible for academic work, clubs, socialization, etc. Attendance Policy Please indicate which day(s) your child will attend Beyond the Bell. Days Attending: Mon. Tue. Wed. Thurs. Dismissal Procedures To ensure the safety of your child at dismissal time, we ask that you or a designated adult (listed on the reverse side of this form) enter the building to sign your child out. In order to keep your child safe, we will be requesting photo identification. No student will be permitted to sign himself/herself out without written permission of a parent/guardian. I do not hold Ridgewood Schools or the MVESC liable for my student s whereabouts once they have signed out of the Beyond the Bell Program for the day.

4 LIST THREE INDIVIDUALS WHO ARE AUTHIZED TO PICK UP THE STUDENT *The Ohio Department of Education requires a minimum of three individuals listed below. DO NOT RELEASE The following people are not allowed to take my student (court papers required) *State Licensing requires that we have the following information for each student. Preferred Physician Preferred Dentist Does student have any food, medication, or environmental allergies? If yes, please list and explain: BEYOND THE BELL HAS PERMISSION to secure emergency transportation for my student in the event of illness or injury. The emergency transportation service will determine the facility to which my child will be transported EMERGENCY MEDICAL AUTHIZATION BEYOND THE BELL DOES NOT HAVE PERMISSION to secure emergency transportation for my student in the event of illness or injury which requires emergency treatment. ACKNOWLEDGEMENT OF POLICIES & PROCEDURES Parent Initials: My child has permission to participate in the Beyond the Bell Afterschool Program. Parent Initials: I have received a Parent Handbook describing the policies & procedures governing the Beyond the Bell Program, funded by the Muskingum Valley Educational Service Center. I am now aware that I may be eligible to receive gas vouchers if my child participates in Ridgewood s Free/Reduced Lunch Program. I understand that Gas Voucher Applications are made available by the Site Coordinator upon request. Parent Initials: I acknowledge that Ridgewood Elementary staff members may share information with the Beyond the Beyond Bell staff regarding my child s academic needs in order to facilitate personalized & quality reading and math intervention/enrichment activities. Parent Initials: The Beyond the Bell Program has my permission to photograph or to video tape activities that may include my child for the purpose of promoting the program. (Example: Newsletter, flyers or news articles) Parent Initials: I give permission for my child to use computer equipment and the internet, acknowledging the inherent risk of the internet. Every effort will be made by the Ridgewood Local Schools and the Muskingum Valley Educational Service Center to protect children from harmful content, including the use of software that blocks offensive content. Unacceptable uses of the computer and/or network by students will result in revoking of access privileges. Parent Initials: I understand that it is my student s responsibility to attend the Beyond the Bell Program on the designated days listed on front of this form. I also understand that a parent/guardian, or other individuals listed above will enter the building and check my student out each day he or she attends. I understand the importance of being at the school by no later than 5:15 p.m. to take my child home. If an emergency arises and it is impossible to be at the school by 5:15, I will contact the school to notify them that I will be arriving late. Parent/Guardian Signature Date:

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