Printable Form:      Elementary / Middle    |     High School
STUDENT INFORMATION
PICK-UP & EARLY RELEASE
Daily attendance is required of students participating in the Expanded Learning Program. The Expanded Learning Program requires programs stay open until 6:00 p.m. and for 15 hours per week. However, it is understood that family commitments, health-related appointments, other outside activities, or safety issues will occur during the Expanded Learning Program hours. For occasions such as these, you may request an early release time for your student to be picked up from program.

California Education Code Section 8483(a) states that:

  1. Every Expanded Learning Program shall commence immediately upon the conclusion of the regular school day, and operate a minimum of 15 hours per week, and at least until 6:00 p.m. on every regular school day.
  2. It is the intent of the Legislature that elementary school and middle school or junior high school pupils participate in the full day of the program every day during which pupils participate, except as allowed by the early release policy pursuant to subparagraph (B)of paragraph (1) of this section or paragraph (2) of subdivision (f) of Section 8483.76.

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 #1


Parent or Guardian #1


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 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 am the parent or legal guardian of, and hereby authorize, the above-named child to participate in the Fresno County Superintendent of School’s Program named above. I understand that my child's participation in the Program is voluntary; and, in consideration of my child being allowed to participate, I am fully informed of the following and hereby agree on behalf of myself and my child, and our representatives, assigns, heirs, next of kin, and executors as follows:

  1. I, the undersigned, am fully informed that the Program may involve activities that are physically, mentally, and emotionally challenging and may involve certain health and safety risks. I fully assume all risks, injuries, and losses to my child and property arising out of, resulting from, or related to the Program.
  2. I, the undersigned, HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE the Fresno County Superintendent of Schools, its officers, employees, representatives, volunteers, and agents (collectively 'FCSS'), and the Fresno County Board of Education, its officers, employees, representatives, volunteers, and agents (collectively 'FCBE') for and from any and all liability to my child, myself, our representative, assigns, heirs, and next of kin for any losses or damages, and any claims or demands therefor on the account of injury to the person or property of, or resulting in death of my child, while my child is traveling to or from, or participating in the Program.
  3. I, the undersigned, HEREBY AGREE TO INDEMNIFY, SAVE, AND HOLD HARMLESS FCSS and FCBE from any injury, loss, liability, damage, and/or cost FCSS and/or FCBE may incur or sustain that are caused by my child while participating in the Program.
  4. I, the undersigned, HEREBY ASSUME FULL RESPONSIBILITY FOR BODILY INJURY, DEATH, OR PROPERTY DAMAGE while my child is participating in the Program.
  5. I, the undersigned, authorize any medical treatment for my child which is deemed necessary in the event of any injury or illness while participating in the Program, and agree that I am responsible for the cost of such medical treatment.
  6. I, the undersigned, further expressly agree that this Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
  7. I, the undersigned, hereby

         

    to the FCSS or any other entity approved by FCSS to take photographs, motion pictures, digital images, sound recordings, and/or DVD/video tapes ('recordings') of my child, singly or in a group during the Program or other FCSS-related activities, for the purpose of informing other students, teachers, parents, and the general public of the aims and activities or methods of instruction of FCSS programs and services.

    1. I understand that these recordings may be shown to local and national audiences, in local newspapers as well as national publications, and may be posted on the Internet. It is agreed that I may inspect or review these recordings upon request.
    2. It is further agreed that neither my child nor I shall have any right, title or interest in the above named recordings, nor shall my child or I have any right to any cause of action for damages or injury resulting from the taking, publication, or dissemination of these recordings for the purpose herein described.
I, the undersigned, HAVE READ, UNDERSTAND, AND VOLUNTARILY SIGN THIS AGREEMENT and further agree that no oral representations, statements, or inducements apart from this Agreement have been made. I understand that by signing this Agreement, I am waiving valuable legal rights.

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


I would like a copy of this form sent to me at the following email address: