<p> SCPS 21ST CCLC STUDENTAPPLICATION Greenwood Lakes Middle School 2017-18</p><p>STUDENT INFORMATION (Legal Name) </p><p>Name: ______Grade______DOB: </p><p>______</p><p>Home Address: ______City______Zip Code:______</p><p>PARENT/GUARDIAN INFORMATION</p><p>Mother: ______Home Phone:______</p><p>Work Phone:______Cell Phone:______Email address:______</p><p>Father: ______Home Phone:______</p><p>Work Phone:______Cell Phone:______Email address:______</p><p>Student lives with (check all that apply):  Both Parents  Mother Only  Father Only  Parent & Step Parent  Grandparent(s)  Other ______</p><p>TRANSPORTATION How will your child get home each day after the program? Please check one. (Please note that if your child’s method of transportation should change, the program staff must be notified by a parent or guardian IN WRITING.) </p><p>[ ] My child will be picked up as a car rider </p><p>[ ] My child will walk home </p><p>Revised 7/18/16 EMERGENCY CONTACTS In the event the parents/guardians cannot be reached, a 21st CCLC staff member will contact the people listed below. </p><p>Name:______Phone:______Relationship to student:______</p><p>Name:______Phone:______Relationship to student:______</p><p>Please list people who you authorize to pick up your child from the after school program. Other than the parent/guardian, all others who pick up the student will be required to show picture identification. No student will be released to anyone who is not listed on the registration form.</p><p>Name:______Phone:______Relationship to student:______</p><p>Name:______Phone:______Relationship to student:______</p><p>MEDICAL INFORMATION Please list any medical conditions/allergies that apply to your child.</p><p>Medication(s) taken by student: ______Physician Name: ______</p><p>Physician Phone Number: ______Preferred Hospital in case of emergency______</p><p>PHOTO PERMISSION FORM (Please Check One)</p><p>___I give permission for my child to be photographed/videotaped with respect to SCPS/21st CCLC activities and events. ___I do not give permission for my child to be photographed/videotaped with respect to SCPS/ 21st CCLC activities and events. </p><p>Revised 7/18/16 PROGRAM PERMISSIONS (Please initial next to each)</p><p>_____MOVIE RATING PERMISSION: As part of an educational experience or activity, under the supervision of the SCPS/21st CCLC staff, my child is granted permission to view presentations and or movies that have a G or PG rating.</p><p>_____DATA COLLECTION: Periodically throughout the year 21st CCLC is required to collect data on physical fitness. We collect this data by conducting fitness drills (curl ups, shuttle run, and 90 degree push-ups). Please initial the line indicating your consent. </p><p>NETWORK ACCESS AGREEMENT: As a condition of being granted access to the Internet through the computer network system maintained, operated, and supervised by the School Board of Seminole County, Florida, I agree to comply with the following terms and conditions. By this agreement, access is only permitted from the SCPS/21st CCLC Grant Sites. 1. I understand that my child has no privacy regarding his/her use of the network access, any material found, detected, or stored on any computer used by my child to access the SCPS network or any material viewed by my child. 2. I understand that my child’s activities will be monitored. 3. I understand that if my child violates this agreement that his/her Seminole County School Board network access may be immediately terminated. The violation may be reported to law enforcement, as appropriate.</p><p>I have reviewed and understand the information provided above. I give my consent and acknowledgement by signing below. With my signature I approve and consent to items stated above.</p><p>______Signature of Parent/Guardian Date</p><p>Revised 7/18/16</p>