South Scranton Intermediate School
After School/ Summer Program Application Grade:_____
September 2016 – June 2017 Homeroom Number: _____
Child’s First Name: ______Child’s Last Name: ______
Date of Birth: _____/_____/_____Child’s Primary Language: ______
Contact Information
Parents or Guardian’s Name: ______
Parents or Guardian’s Primary Language: ______
Address: ______Home Phone Number: (_____) ______
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Mother/ Guardian’s Work Number: (_____) ______Father/ Guardian’s Work Number: (_____) ______
Mother/ Guardian’s Cell Number: (_____) ______Father/ Guardian’s Cell Number: (_____) ______
Child Lives with: ____ father____ Mother ____Step Parents ____ Foster _____ Legal Guardian ____ Other
Pick Up Information
How do you want your child get home from the program: _____ Bus_____ Pick Up (Car)
Person(s) authorized to pick up your child / Emergency Contacts (MUST show picture I.D)
Name: ______Relationship: ______Phone Number: (_____) ______
Name: ______Relationship: ______Phone Number: (_____) ______
Medical Information
Is your child under medical care or taking any medication (s)?_____ yes_____ no
If yes, check all of the following conditions that your child has & indicate if medication needs to be dispensed at school.
____ Bee Sting AllergyEpi-pen: ____ Yes ____ No
____ AsthmaInhaler: ____Yes ____ No
____ DiabetesInsulin: ____Yes ____ No
____ Vision/ HearingGlasses: ____ Yes ____ No; Hearing Aids: _____ Yes ____ No
Other Allergies: ______
Other Special Needs/ Disabilities: ______
Physician’s Name: ______Phone Number: (_____) ______
Address: ______Medi-Cal: _____ yes _____ no
Health Insurance Number: ______
Pick the days you would like to attend as well as the activity you would like to participate in, you can only pick one activity per day, we are NOT rotating this year; 30 kids per activity on a first come first serve basis:
**Homework Help is offered every day before clubs. See back of information sheet for club descriptions.
______Monday : ______Minecraftor ______Craft Corner
______Tuesday:______Magicor ______CSI (Crime Scene Investigation)
______Wednesday:______NASA (Astronomy)or ______Mixed Tape
______Thursday:______We Be Bookinor ______Board Games
Photo Release
Does South Scranton Intermediate School’s After School/ Summer Program have permission to use photos of your child in educational or promotional materials? _____ Yes ______No
Please Read and Sign Below
I understand thatSouth Scranton Intermediate School’s After School/ Summer Program is a FREE program. These services are possible through state grants and district funding. I give permission for staff to review my child’s academic files for the purposes of analyzing program effectiveness and reporting to funding sources.
Parent Guardian Signature: ______Date: ______
Student Data Permission Form
You have enrolled your student in theSouth Scranton Intermediate School’s After School/ Summer Program. This program is funded by the Pennsylvania Department of Education. Our use of this funding requires that we report certain results to the Department including academics, attendance, discipline, behavior, activity participation, and classroom performance. In addition to compliance with reporting requirements, use of this data assists program managers in making informed decisions about program adjustments and improvements, matching students with needs, program sustainability, and program replication in other sites. Our reporting of positive student results may increase our chances of securing continued or additional funding to operate this program.
While the program will collect and maintain information about your student’s participation and attendance at our program, there s certain data that the South Scranton Intermediate School’s After School/ Summer Program must collect from your child’s school. This Includes:
School Attendance
Student Assessment Data
Report Card Grades
School Discipline Data
Feedback from Teachers and Administration
The South Scranton Intermediate School’s After School/ Summer Program’s plan to safeguard student, teacher, and school data can be obtained from Nancy Hlavaty:
All information collected will be restricted and used solely for serving student needs and approved program evaluation purposes. Each staff member who has access to data receives proper training and ongoing updates on the importance of confidentiality of the data, including the specifics of the Family Educational Rights and Privacy Act (FERPA). Information can be found at USDE’s FERPA page:
The South Scranton Intermediate School’s After School/ Summer Program will not release under any circumstances, identifiable information to any other person or organization without written consent from the student, parent, or individual. According to FERPA, the following information is considered “directory” information and may be disclosed without consent: student’s name, address, telephone number, date and place of birth, honors and awards, and dates of attendance.
By my signature, I authorize the South Scranton Intermediate School’s After School/ Summer Program to collect and maintain data for my student named below for the purposes of matching my student to services and for program evaluation and reporting. I understand that my student will not be identifiable in any reports to entities or individuals outside of the school district.
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Parent/ Guardian Name (Please Print)Student Name (Please Print)
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Parent/ Guardian Signature Date