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Recent
After School Enrichment Program
Online Lottery Registration Form - 1 per Child
The Online Application Lottery ended on October 16th at 11:59 pm. Before completing this application, please contact your site coordinator to verify space availability at the site you would like your child to attend. A $47 registration fee and weekly fee due at the time of application. Thank you
Site/Program Information:
School Year:
2020 - 2021
Site Choice*:
[-- Select Site --]
[-- Pre-K Schools--]
Hickory Grove Pre-K
Highland Mill Pre-K
Park Road-Pre-K
Trillium Springs Pre-K
University Meadows-Pre-K
[-- Elementary Schools--]
Albemarle Road
Bain
Ballantyne
Barnette Elementary
Berewick Elementary
Beverly Woods
Billingsville
Blythe
Chantilly
Clear Creek
Collinswood (K-8th)
Cornelius
Cotswold
Croft Community
Crown Point
David Cox Road
Davidson Elem
Dilworth-Latta Campus
Druid Hills
Eastover
EE Waddell Language Academy
Elizabeth Lane
Elizabeth Traditional
Elon Park
Endhaven
First Ward
Governor's Village STEM 5-8
Governor's Village STEM Academy 5-8
Governor's Village STEM Academy K-4
Grand Oak
Greenway Park
Hawk Ridge
Hickory Grove
Highland Creek
Highland Mill
Highland Renaissance
Hornets Nest
Huntersville
Huntingtowne Farms
Idlewild
Irwin Academic Center
J. H. Gunn
J.V. Washam
Joseph W. Grier
Lake Wylie
Lansdowne
Lebanon Road
Long Creek
Mallard Creek
Matthews
McAlpine
McKee Road
Mountain Island Lake Academy
Myers Park Traditional
Newell
Oakdale
Oakhust
Oaklawn (K-8th)
Olde Providence
Palisades Park
Park Road
Parkside Elementary
Paw Creek
Pineville
Pinewood
Piney Grove
Polo Ridge
Providence Spring
Rama Road
Rea Farm
Reedy Creek
Renaissance West
River Gate Elementary
River Oaks Academy
Selwyn
Shamrock Gardens
Sharon
Smithfield
Statesville Road
Steele Creek
Stoney Creek
Torrence Creek
Trillium Springs
University Meadows
Vaughan Academy of Technology
Whitewater Academy
Winding Springs
Winget Park
[-- Middle Schools--]
Bailey
Bradley
Community House
J.M. Alexander
Mint Hill MS
Piedmont Open
Randolph
Ridge Road
Program(s) Choice*:
Before School
After School
Would you like to attend Wednesday's Teacher Work Days?
Yes
No
Student Information:
Child's Student ID Number*:
NOTE:
Leave blank for rising PreK or Kindergarten Students
Child's Name*:
(Last)
(First)
(Middle / Nickname)
Child's Address*:
(Street)
(City)
(Zip)
Child Lives With*:
Age*:
DOB*:
Date
Gender*:
Male
Female
Fall
2020
Grade*:
PreK
K
1
2
3
4
5
6
7
8
Daytime School*:
Parent/Guardian Information:
Parent 1
Name*:
Relationship*:
Address*:
Home Phone*:
Place of Employment*:
Mobile Phone*:
Email*:
Work Phone*:
Parent 2
Name:
Relationship:
Address:
Home Phone:
Place of Employment:
Mobile Phone:
Email:
Work Phone:
Fees will be paid by*:
Parent/Guardian
CCRI
Online
Other Source
https://webpay.easydraft.com/CS/CMS-ASEP
Persons (age 16 or older) authorized to pick up child other than parents:
Name
Relationship
Address
Phone
1.
2.
3.
Information about your child*:
Does your child have an IEP or 504 Plan? (
Answering this question will not prevent your child from participating in ASEP.
)
IEP:
Yes
No
504 Plan:
Yes
No
List any allergies and the symptoms and type of response for these health care needs or concerns.
Please add NA for Not Applicable.
You have used
0
of 350 total characters.
List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns.
Please add NA for Not Applicable.
You have used
0
of 350 total characters.
List any particular fears, unique behavior characteristics or special needs the child has.
Please add NA for Not Applicable.
You have used
0
of 350 total characters.
List any types of medication taken for health care needs.
Please add NA for Not Applicable.
You have used
0
of 350 total characters.
Share any other information that has a direct bearing on assuring safe medical treatment for your child.
Please add NA for Not Applicable.
You have used
0
of 350 total characters.
Insurance Information:
Insurance is required for all children enrolled in the After School Enrichment Program. You may choose to purchase student accident insurance in the fall at the school, medical insurance or your own, or both. Please indicate insurance coverage for your child. (
*You must select one option
)
I will enroll my child in the student accident insurance program in the fall
I have personal medical insurance for my child
Insurance Company:
Policy Number:
Emergency Care Information:
Child's Doctor Name*:
Phone*:
Address*:
Hospital Preference*:
If parent/guardian cannot be reached, call
Name*:
Phone*:
Relationship*:
Please note all information in the following section is required and must be completed.
Agreement 1
I the undersigned parent/guardian of
, agree that the ASEP Site Coordinator may authorize the physician of her/his choice to provide emergency care in the event that neither I nor a family physician can be contacted immediately.
I Agree
Date:
Agreement 2
I the undersigned parent/guardian of
, do hereby state that I have read and received a copy of the
Discipline and Behavior Management Policy
and that the Site Coordinator (or other designated staff member) has discussed any questions I had about the Discipline and Behavior Management Policy with me.
I Agree
Date:
Agreement 3
I the undersigned parent/guardian of
, do hereby state that I have read understand the
ASEP Family Guidelines
, the
NC Summary of Childcare Laws
and that the Site Coordinator (or other designated staff member) has discussed any questions I had about the ASEP Family Guidelines and the Summary of Childcare Laws with me.
I Agree
Date:
* Indicates Required Information