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STUDENT APPLICATION - In-Person Expanded Learning Program (School Year)

STUDENT INFORMATION

PICK-UP & EARLY RELEASE

Daily attendance is required of students participating in the Expanded Learning Program. Due to COVID-19 and adjustments being made to program start and end times, please check with your school's ELP Site Lead for specific program hours.
Early Release Justification: Please select a code from the four options below to tell us the reason your student(s) need to leave early (any time before 6pm) on each day of the week. If your student does not need to leave before 6pm, no code is needed.
Day of the Week Time student will be leaving program Early Release Code
If student is leaving program before 6pm		 Reason
Example: My son is in a soccer league on Wednesdays at 5pm
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
For students who are walking home (Release Code 1): All student walkers will be released from program at the same time each day, at a time determined by the Expanded Learning Program.

Parent or Guardian

Parent or Guardian

Is there any COURT-MANDATED custody/visitation orders limiting access to this student?
     
If Yes, please attach a legal order.
Student lives with:
                 
Below, indicate individuals that you permit to pick-up your student from the Expanded Learning Program. For safety reasons, your son/daughter will ONLY be released to the individuals listed below. Those picking up students may be asked to present ID before your student will be released from program. If you wish to add/change names, you must contact the Expanded Learning Program.

MEDICAL & EMERGENCY

If your child requires medication at school, all medication sent to school must be in the original prescription container with a current date and the child's name.

Medical Conditions

Wears glasses/contacts:
           
Severe allergies requiring:
If checked:
If checked:
I/we, confirm that I/we are the parent or legal guardian of , a minor, do hereby give authorization and consent to the Expanded Learning Programs to obtain emergency medical care and necessary transportation, including x-ray examination, anesthetic, medical or surgical diagnosis and emergency hospital which is deemed advisable by and is to be rendered under the general or specific supervision of medical and emergency room staff licensed under the provisions of the medicine practice act and the State of California Department of Public Health.

I/we understand that effort shall be made to contact you or the emergency contacts prior to rendering treatment to the student, but that any of the above treatment will not be withheld if the undersigned or authorized adults cannot be reached. It is understood that your child will be taken to the nearest available hospital for emergency care, unless otherwise specified here.
is my desired hospital.

I/we understand that the school district does not provide accident/medical insurance for students, and I/we further understand that all costs related to medical treatment may be my/our responsibility and not that of the school district or Fresno County Superintendent of Schools.

RELEASE & PERMISSIONS

   By initialing here, I give my son/daughter permission to attend the Expanded Learning Program beginning at the conclusion of the regular school day until the program’s dismissal or early release time. I am aware my son/daughter must be picked up by the dismissal time or have a documented early release time. I understand anyone picking up my son/daughter may be required to provide identification to the Expanded Learning Program staff.
   By initialing here, I give permission for my son/daughter to be interviewed, photographed, and/or videotaped while participating in the Expanded Learning Program. I am aware there are times the program may be featured in news stories and reporters, photographers, and/or film crews from television, radio stations, and newspapers may wish to interview my son/daughter. I understand that such photographs, video recordings, and/or reports will be property of the Expanded Learning and may be used ONLY for the purpose of documenting or publicizing the Expanded Learning Program through print, web, and social media.
   By initialing here, I acknowledge I have read the attached After School Program attendance guidelines and program policies. I understand my son/daughter and parent/guardians must follow these guidelines and policies in order to participate in the Expanded Learning Program.
   By initialing here, I give my permission for program staff to sign-out my son/daughter from program for reasons including but not limited to he/she is walking home, is picked-up early, or receiving district transportation.
   By initialing here, I permit my son/daughter to view movies during the Expanded Learning Program, in accordance with the school district’s policy. I understand that as part of the Expanded Learning enrichment and classroom academic activities, instructors may occasionally show movies to the Expanded Learning participants. The Expanded Learning Program will choose movies in accordance with the school district’s movie selection guidelines. This form will serve as a permission slip.
   By initialing here, I give my permission to my student(s) to sign themselves out of program to walk home or take district transportation.
   By initialing here, permit my student to participate in after school surveys. I understand that my student is being asked to be a part of an Expanded Learning Program Student Survey, being administered through the Fresno County Superintendent of Schools. The survey will be given twice this school year, as a pre-survey in October and post-survey in May. This is a very important survey that will help us evaluate and improve the Expanded Learning program, which offers your child activities designed to promote academic achievement and the development of positive social and emotional skills.

  • Survey Content. The survey gathers information on how well the after school program supports development of socio-emotional skills related to school success including growth mindset, self-perceptions of academic competence, self-regulation, school engagement, perceptions of social competence, self-efficacy, concern for others, and/or grit/perseverance.
  • It is Voluntary. Your child does not have to take the survey. Students who participate only have to answer the questions they want to answer and they may stop taking it at any time.
  • It is Confidential. The results from this survey will be compiled into county-level reports used for evaluation of the Expanded Learning program. No individual student results will be reported. Results will be made available for analysis only under conditions of strict confidentiality. Your child’s last name and birthday will be asked on the survey form, only for the purpose of matching the pre-survey with the post-survey.
  • Potential Risks. There are no known risks of physical, psychological, or social harm to your child.
  • For Further Information. If you have any questions about this survey, about your rights, or do not want your child to participate in this survey, please call the Fresno County Superintendent of Schools, Department of Safe and Healthy Kids at 559-497-3887.
I declare that I am the parent/legal guardian of the named student and the information on this three-page application is true and correct. I will notify the Expanded Learning Program if there are changes to any information stated in the application.

Parent/Guardian Signature

Clear Signature
I would like a copy of this form sent to me at the following email address:
Submit Form Submit / Add Another