FORT COBB BROXTON SCHOOLS

FORT COBB

BROXTON SCHOOLS BROXTON SCHOOLS

A-3 Enrollment Form

We have decided to leave 2nd semester enrollment open for now to allow parent/guardians to enroll students as the Covid numbers improve or more people get vaccinated. We must have a completed enrollment for your child to be enrolled in A-3 After School and start attending. Your child may not begin attending until the following Tuesday after the enrollment is returned. A3 will continue to offer virtual A-3 on Monday and Wednesday this semester for virtual students. If you would like your child to attend the virtual option, please send an email to rwade@fcbmustangs.com to let us know. Students already enrolled in A-3 do not need to re-enroll. If you have any questions, please call Natalie Lierle at (405) 590-5550 or Robin Wade-Lynn at (580) 458-2868.

Please Fill Out The A-3 Enrollment Form Below

Grade

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th

7th Grade

8th Grade

Child's Last Name:

Child's First Name:

STUDENT'S FULL LEGAL NAME AS ON BIRTH CERTIFICATE, ADOPTION PAPERS, ETC.:

Last Name:

First Name:

Mailing Address:

Physical Address:

City:

State:

Zip:

Phone Number:

Please choose one or more:

African American

American Indian

Asian

Pacific Islander

White/Caucasian

Parent/Guardian Information

Parent/Guardian Name:

Relationship to Student:

Parent (Natural or Legally Adopted)

Step-parent

Legal Guardian

Foster Parent

Other

Mailing Address (If different from student mailing address):

City:

State:

Zip Code:

Place of Employment:

Work Phone:

Home Phone/Cell Phone:

Cell Phone(s): (These Phones may receive text messages or notifications)

#1 Contact Choice (Will receive text):

#2 Contact Choice:

I give Fort Cobb-Broxton A-3 After School personnel permission to use these means listed, including text messaging, as a means to contact me or my child concerning school related topics. I understand that I may receive information regarding my child(ren) to include, but not be limited to, after school cancellations, field trip notes, and other information specific to the after school program. Parent/Guardian Signature:

Second Parent/Guardian

Parent/Guardian Name:

Relationship to Student:

Parent (Natural or Legally Adopted)

Step-parent

Legal Guardian

Foster Parent

Other

Mailing Address (If different from student mailing address):

City:

State:

Zip Code:

Place of Employment:

Work Phone:

Home Phone/Cell Phone:

Cell Phone(s): (These Phones may receive text messages or notifications)

Emergency Contact Information

*** We must have at least 2 contacts and a good working phone number at all times.***

PERSON TO CONTACT IN CASE OF EMERGENCY. In order of contact preference:

Name

Phone Number

Relationship:

Name:

Phone Number:

Relationship:

Enrollment

After School 3:00-5:30 pm (K - 8th)

Tuesday

Thursday

My child will be picked up from school at the designated classroom for their grade by 5:30 p.m. by (list people allowed to pick them up below this section.)

My child is allowed to walk home alone by himself/herself from the program. If both options are selected students who have permission to walk that aren’t picked up will be released at 5:30 pm.

Parent/Guardian Signature:

Protecting Your Child

Parent/Guardian: So that the after school program can better protect your child while he/she is at school, we ask that you make a list of those individuals who can pick up your child from school. You may add or delete any names by coming into the office and updating your list. Should anyone not on the list come to school to pick up your child we would notify you by phone and you could tell us what to do. Child's Name:

Name:

Relation:

Name:

Relation:

Name:

Relation:

Name:

Relation:

Name:

Relation:

Student Health History

Does your child have any food allergies or medical conditions we should know about?

Does your child have any physical conditions we should know about while playing games/activities?

List any medicine taken on a daily basis:

The Tylenol/Acetaminophen and Chewable antacid are on hand in the office for students with, headache, mild pain, or upset stomach. Please initial which of these you give permission for school personnel to administer to your child:

Tylenol/Acetaminophen

Chewable Antacid

Cough Drops

I do not wish for my child to receive any medication at school:

Parent/Guardian Signature:

Date

Photo/Name Release

The project will be collecting photographs to be used in FCB A-3 After School Program written materials, such as newsletters, website, or newspapers. Do you give permission for your child’s photo to be used?

Yes I give A-3 After School Permission

No I Do Not give A-3 After School Permission

Signature of Parent/Guardian:

For K-5th Grade: I understand that if there is a change of plans for the day and I do not call or send a note on my child’s regular after school enrollment day, they will be kept at after school. 6th-8th Grade students should know what they are doing each day and do not need a phone call or note. Parent/Guardian Signature:

I give FCB A-3 After School Program permission to include my child in the daily routines of their program. I understand that Fort Cobb-Broxton Public Schools is only the tool of 21st Century Grant and there is a difference between the FCB A-3 After School Program and the regular education school day. I have read the information and understand that data will be gathered during the FCB A-3 After School Program and grant permission for my child to participate in the related program activities. Parent/Guardian Signature

I understand that some type of physical activity is required by the grant. If there is no physical activity choice for my child’s age group they will attend a class wide physical activity. My child cannot be excused from their physical activity group or choice. Parent/Guardian Signature:

I understand there will be no early pick-ups between 5:00 and 5:15 pm. A-3 will begin releasing students at 5:15 pm. Parents/Guardians must be on time to pick up their child promptly before 5:30 pm. Parent/Guardian Signature:

Date:

Epinephrine Injection Policy

All school personnel employed by or acting on behalf of the Fort Cobb-Broxton school system may administer epinephrine via an undesignated epinephrine auto-injector to an individual if the staff member in good faith believes an individual is experiencing a potentially life-threatening allergic reaction (anaphylaxis). A school employee will call 911 as soon as possible if it is believed that a student is having an anaphylactic reaction. Parent/Guardian Signature:

Date:

Physical aggression against other participants or staff or running away from program activities may result in immediate suspension after the first incident. Participants will forfeit their space from the program for the following reasons: excessive absences, behavior that threatens physical or emotional safety of self or others, or breaking any school rules that are deemed worthy of termination. The program directors’ decision is final.

I hereby certify that I am the custodial parent and legal guardian or have obtained legal guardianship through the courts for the student listed above. I certify that I have verified my address to be a legal residence within the Fort Cobb-Broxton Public Schools, Independent School District I-167. I also certify that all of the above information is true and correct. I also understand that A-3 After School is not responsible for lost or broken personal items. By typing your name in the signature boxes of this form, you agree that this is valid as your signature. Parent/Guardian Signature:

Date:

A-3 After School does not discriminate against employees or students, on the basis of age, color, disability, gender, gender identity, gender expression, national origin, political affiliation, race, religion, sexual orientation, or any other basis protected by law.

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