School District

School

Student Information

First Name

Middle Initial

Last Name

Date of Birth

Grade

Gender

Race

Primary Language

Eligible for Free/Reduced Lunch?

YesNo

Address

Address 2

City

State

Zip Code

Add 2nd Student?

2nd Student Information

First Name

Middle Initial

Last Name

Date of Birth

Grade

Gender

Race

Add 3rd Student?

3rd Student Information

First Name

Middle Initial

Last Name

Date of Birth

Grade

Gender

Race

Parent/Guardian Info

First Name

Last Name

Home Phone

Cell Phone

Email

Relation to student

Employer Name

Work Phone

Does this parent/guardian live at the same address as the student(s)?

YesNo

Address

Address 2

City

State

Zip Code

Add 2nd Parent/Guardian?

2nd Parent/Guardian Info

First Name

Last Name

Home Number

Cell Number

Email

Relation to student

Employer Name

Work Phone

Does this parent/guardian live at the same address as the student(s)?

YesNo

Address

Address 2

City

State

Zip Code

Sign-Offs and Consent

Parent Handbook Consent

I (the understated) agree that I have received the Accelerate to Great After-School Parent Handbook. I agree to follow and abide by the policies and procedures outlined in the handbook. I understand that it is my responsibility to read and know all of the policies and procedures outlined within this handbook. If I have any question(s) I will ask the Program Site Manager.

Initial

Parent handbooks for all programs can be found at www.waynemetro.org/afterschool

General Release of Liability

I understand that Accelerate to Great program ends at the time specified in the handbook Monday-Thursday. Furthermore, I acknowledge that my child will be required to sign himself/herself out of the program at the end of program. 21st CCLC Accelerate to Great staff and its partners or affiliates will not be responsible for students picked up late from the program. Three late pick ups will result in student being dropped from the program.

Initial

Medical Treatment Consent

I certify that my child is not suffering from any condition, physical, or otherwise that may prevent him/her from participating in any planned activity. If a medical emergency should arise regarding my child, I hereby grant Accelerate to Great / Wayne-Metropolitan CAA permission to select a physician and/or hospital for my child’s care and to administer any emergency medical treatment which my child may require. I also give medical personnel and/or the hospital my permission to treat my child at the request of representatives of Wayne-Metropolitan CAA. I will assume responsibility for my child’s health while in the 21st CCLC Accelerate to Great program. Should any above stated health condition change, I will promptly notify the Site Manager. I grant permission for my child(ren) to participate in all Accelerate to Great After School Program activities. The program staff and those operating the Accelerate to Great After School Program are authorized to consent to emergency medical treatment, if the need arises while this child is in the program. I agree to pay all costs incurred to provide such medical care. I have listed medical information important in treating this child on the registration form. I understand that Wayne Metro CAA, its officers, representatives, and employees, whether voluntary or employed, assume no responsibility whatsoever for any injury suffered by or medical emergency occurring to this child in the course of the program. I hereby release, exonerate, and discharge Wayne Metro CAA and its officers, representatives, and employees, from any and all liability, damages, actions or causes of actions for any injuries suffered by or medical emergency occurring to this/these children while enrolled in the Accelerate to Great After School Program.

Initial

Written Information Packet Documentation

A written information packet has been provided at the time of enrollment. The packet included all the following information:

Criteria for admission and withdrawal.
Schedule of operation, denoting hours, days, and holidays during which the center is open and services are provided.
Fee policy.
Discipline policy.
Food service program.
Program philosophy.
Typical daily routine.
Parent notification plan for accidents, injuries, incidents, illnesses.
Exclusion policy for child illnesses.
Notice of the availability of the center’s licensing notebook

○ The licensing notebook contains all the licensing inspection and special investigation reports and related corrective action plans since May 28, 2010.

○ The licensing notebook is available to parents during regular business hours.

○ Licensing inspection and special investigation reports from at least the past two years are available on the child care licensing website at www.michigan.gov/michildcare.

I certify that I received all of the above items.

Initial

21st Century Literacy Enrichment Consent

I understand that 21st CCLC are dedicated, focused and committed to “Every Student Succeeds Act.” Therefore, staff and educators will need to be informed of any special needs my child may have. I understand that the information will be kept confidential and used for academic purposes or my child’s safety. If my child has a special need I understand that I should indicate below or discuss with the Site Manager so that my child may receive the proper assistance needed to succeed in the Accelerate to Great program. In addition, I give Wayne-Metropolitan CAA and its entity 21st CCLC and their partner’s permission to gather my child’s grades, test results, and other information related to his/her academic needs for evaluation purposes. This information will be kept confidential for the sole purpose of academic and social enrichment needs.

Initial

Statement of child(ren)'s health and immunizations (rule 1809)

I state that my child(ren) is:

free from health conditions which could pose a risk to other children or adults,
has no limitations or special needs regarding participation in daily activities.
has a health or handicapping condition which could pose a risk to my child in care and I have attached a statement indicating the
limits of participation and any special needs or treatment while in care.

My child(ren) has completed or is in progress of receiving immunizations and booster as recommended by the Department of Community Health.

YesNo

If NO, specify reason:

ReligionOther (explain below)

I certify that my child’s immunization record or the appropriate waiver is on file with my child's school and is up to date.

Initial

Field Trip Transportation

I hereby give my permission to: 21st CCLC Accelerate to Great for my child(ren) to walk or be transported in a vehicle and participate in field trips. I realize that I will be given a separate permission slip and information prior to each field trip that must be signed and returned for my child to participate.

YesNo

Media Release

I give permission for photographs and/or video to be taken of my child for program newsletters, program publications, news media, etc

YesNo

Movies

I give permission for my student to view G and PG rated movies shown for the purpose of education or entertainment.

YesNo

Virtual Program Release

I,

, (“Student”) wish to receive academic and other support from Wayne Metro’s A2G – 21st Century Community Learning Center during the 2021-2022 School Year (“Services”). Typically, Services are provided to students face-to-face and on-site in a school building. However, due to COVID-19 and related precautions, such Services will now be provided to students on-line (“Online Services). The Online Services will be accessed via Google Meet and/or Zoom.I understand that there is no guarantee that a teacher or staff member of Detroit Public Schools Community District will be present during the online session(s). I release Detroit Public Schools Community District from any and all claims, losses, damages, injuries, and liabilities and waive all rights in connection with my participation in Online Services. This Release will be governed by the laws of the State of Michigan. By signing below, I attest that I have read and I understand all of the terms of this Release and that I agree to be bound by all of them.

Student Signature:

Name:

Address:

Date:

NOTE TO STUDENT: If you are under 18 or are a minor in the state of your residence, this Release must be signed by your parent or legal guardian.

TO BE COMPLETED BY PARENT/LEGAL GUARDIAN IF THE SUBJECT IS A MINOR

I warrant that I am the Parent/Legal Guardian of the above-named Subject and that I have the full legal right and capacity to sign this Release. I have read and I understand all of the terms of this Release and I agree to be bound by all of them on behalf of myself and my child/ward. I am aware that all sessions of Online Services will be made accessible to me, other parents or guardians of my child/ward, and District personnel by the Partner.

Signature:

Name:

Relationship to Subject:

Address:

Date:

2nd Student Virtual Program Release

I,

, (“Student”) wish to receive academic and other support from Wayne Metro’s A2G – 21st Century Community Learning Center during the 2021-2022 School Year (“Services”). Typically, Services are provided to students face-to-face and on-site in a school building. However, due to COVID-19 and related precautions, such Services will now be provided to students on-line (“Online Services). The Online Services will be accessed via Google Meet and/or Zoom.I understand that there is no guarantee that a teacher or staff member of Detroit Public Schools Community District will be present during the online session(s). I release Detroit Public Schools Community District from any and all claims, losses, damages, injuries, and liabilities and waive all rights in connection with my participation in Online Services. This Release will be governed by the laws of the State of Michigan. By signing below, I attest that I have read and I understand all of the terms of this Release and that I agree to be bound by all of them.

Student Signature:

Name:

Address:

Date:

NOTE TO STUDENT: If you are under 18 or are a minor in the state of your residence, this Release must be signed by your parent or legal guardian.

TO BE COMPLETED BY PARENT/LEGAL GUARDIAN IF THE SUBJECT IS A MINOR

I warrant that I am the Parent/Legal Guardian of the above-named Subject and that I have the full legal right and capacity to sign this Release. I have read and I understand all of the terms of this Release and I agree to be bound by all of them on behalf of myself and my child/ward. I am aware that all sessions of Online Services will be made accessible to me, other parents or guardians of my child/ward, and District personnel by the Partner.

Signature:

Name:

Relationship to Subject:

Address:

Date:

3rd Student

I,

, (“Student”) wish to receive academic and other support from Wayne Metro’s A2G – 21st Century Community Learning Center during the 2021-2022 School Year (“Services”). Typically, Services are provided to students face-to-face and on-site in a school building. However, due to COVID-19 and related precautions, such Services will now be provided to students on-line (“Online Services). The Online Services will be accessed via Google Meet and/or Zoom.I understand that there is no guarantee that a teacher or staff member of Detroit Public Schools Community District will be present during the online session(s). I release Detroit Public Schools Community District from any and all claims, losses, damages, injuries, and liabilities and waive all rights in connection with my participation in Online Services. This Release will be governed by the laws of the State of Michigan. By signing below, I attest that I have read and I understand all of the terms of this Release and that I agree to be bound by all of them.

Student Signature:

Name:

Address:

Date:

NOTE TO STUDENT: If you are under 18 or are a minor in the state of your residence, this Release must be signed by your parent or legal guardian.

TO BE COMPLETED BY PARENT/LEGAL GUARDIAN IF THE SUBJECT IS A MINOR

I warrant that I am the Parent/Legal Guardian of the above-named Subject and that I have the full legal right and capacity to sign this Release. I have read and I understand all of the terms of this Release and I agree to be bound by all of them on behalf of myself and my child/ward. I am aware that all sessions of Online Services will be made accessible to me, other parents or guardians of my child/ward, and District personnel by the Partner.

Signature:

Name:

Relationship to Subject:

Address:

Date:

Child Information Record

State of Michigan - Department of Licensing and Regulatory Affairs - Child Care Licensing

Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply, “unknown” or “none” is the required response. A blank field, a line through a field or “N/A” are not acceptable responses.

For Provider Use Only:

Date of Admission

Date of Discharge

Student Information

Name of Child (Last, First, Middle Initial)

Child's Date of Birth

Name of Child (Last, First, Middle Initial)

Child's Date of Birth

Name of Child (Last, First, Middle Initial)

Child's Date of Birth

Address (Number and Street, Building/Apartment Number)

City

State

Zip Code

Parent/Guardian Information

Parent/Legal Guardian’s Name

Primary Phone

2nd Phone (if applicable)

Home Address (if not child’s address)

City

State

Zip Code

Home Address (if not child’s address)

City

State

Zip Code

Email Address (optional)

Employer Name

Work Phone

2nd Parent/Guardian Information

Parent/Legal Guardian’s Name

Primary Phone

2nd Phone (if applicable)

Home Address (if not child’s address)

City

State

Zip Code

Home Address (if not child’s address)

City

State

Zip Code

Email Address (optional)

Employer Name

Work Phone

2nd Parent/Guardian Information

Parent/Legal Guardian’s Name

Home Phone

Home Address (if not child’s address)

Cell Phone

City

State

Zip Code

Email Address (optional)

Employer Name

Work Phone

Health/Physician Information

Name of Child’s Physician or Health Clinic

Physician’s or Health Clinic’s Phone Number

Hospital Preferred for Emergency Treatment (optional)

Allergies, Special Needs and/or Special Instructions?

YesNo

If yes, explain:

(Attach additional sheets, if necessary.)

Emergency Contact & Release of Child

Emergency Contact & Release of Child: List all individuals, including parents/legal guardians, in order of preference, to be contacted in an emergency. If possible, include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released. The second phone number column can be left blank. (If more individuals, attach additional sheets.)

Contact 1

Contact 1 Phone #

Contact 1 alt phone#

Contact 2

Contact 2 Phone #

Contact 2 alt phone#

Contact 3

Contact 3 Phone #

Contact 3 alt phone#

Release of Child Only

Release of Child Only: List all individuals, other than the parents/legal guardians, to whom the child may be released. (If more individuals, attach additional sheets.)

Individual 1

Phone #

Individual 2

Contact 2 Phone #

Individual 3

Contact 3 Phone #

Individual 4

Contact 4 Phone #

Parent/Legal Guardian Initials

I give permission to Wayne Metro CAA, licensed by the Department of Licensing and Regulatory Affairs to secure emergency medical treatment for the above named minor child while in care.

I certify that I accurately completed this form and if anything changes, I will notify the provider by updating this form

Signature of Parent or Guardian

Date Signed

Date Card Reviewed

Parent or Legal Guardian Initials

Date Card Reviewed

Parent or Legal Guardian Initials

Date Card Reviewed

Parent or Legal Guardian Initials

Date Card Reviewed

Parent or Legal Guardian Initials

LARA is an equal opportunity employer/program.

AUTHORITY: 1973 PA 116
COMPLETION: Required
PENALTY: Rule Violation

CCL-3731 (Rev. 3/17/2022) Previous editions 7-18 & 4-21 may be used