AfterSchool Application - LearningWorks

School Info

What schools does the student attend?

Biddeford Intermediate School
Biddeford Primary School
East End Community School
Kaler Elementary School
Ocean Ave. Elementary School
Presumpscot Elementary School
Reiche Community School
Riverton Elementary School
Rowe Elementary School
Skillin Elementary School
Waterboro Elementary School

Who is the classroom teacher that is referring this student?

Please note that we will check with the teacher to confirm that he or she has referred your child to the program.

School ID number (if known)

Student Info

Student name

Grade

Gender

Date of Birth

Address

Street Address Address Line 2 City State ZIP Code

Primary parent/guardian name

Primary parent/guardian phone number

Does primary contact need an interpreter/translator when called?

Yes
No

If so, what language?

Primary parent/guardian e-mail address

Email is used for program announcements and communications with staff and will be kept confidential.

Medical Needs

If student needs access to meds during program hours, please contact the Site Coordinator for further information. Some of our sites have access to Epi-Pens and inhalers, others do not.

Please list any medical needs and/or allergies:

Does the child carry an Epi-Pen?

Yes
No

Does the child carry an inhaler?

Yes
No

Emergency contact (other than primary parent)

Emergency contact phone number

Transportation

If requested, transportation home is provided for eligible students. Students may need to walk up to a half-mile home from corner bus stops. The LWAS site coordinator will contact you with bus details, if your child is eligible.

Are you requesting bus transportation?

Yes
No

Who is authorized to pick up your child?

Program Releases

I give permission for my child to attend LearningWorks Afterschool.

Yes
No

I give permission for my child to participate in field trips off school property during program hours.

Yes
No

I give permission for emergency medical treatment to be given to my child if I cannot be reached by phone.

Yes
No

In consideration for being allowed participant privileges in the LearningWorks 21st CCLC Program, I hereby assume full responsibility for any risk of bodily injury, death, or property damage and/or while using the premises or any facilities or equipment heron. I understand that this program includes physical activity (including swimming) and I also understand that any program or sport that includes such activity carries with it an inherent risk of physical injury. I further agree to hold harmless the LearningWorks 21st CCLC program, their partners, directors, officers, employees, agents, and volunteers from any and all claims that may result from any action for damages, including but not limited, to such claims that may result from injury or death, accident or otherwise, during or arising in any way from said activity. I acknowledge that this General Release of Liability of the LearningWorks/21st CCLC Program and Portland School Department and its partners is binding on me and my heirs, personal representatives, successors, and assigns.

Yes
No

I give permission to LearningWorks to give and receive information (academic progress, demographic, free and reduced lunch status, special services, MEDMS #, and behavior) of my child for the purposes reporting requirements to our funders and of coordination of services with the staff at the school and at LearningWorks.

Yes
No

Parent/Guardian Signature

Date

Photograph/Media Release (optional)

I hereby consent to the use of my child’s name, likeness and speech in any audio tape, video tape, film or photograph made in any LearningWorks Program activity for the business or publicity purposes of the program and its partners. I expressly release LearningWorks and its licensees, assignees, affiliates and successors from any privacy, defamation, or other partners have arising out of web publication, broadcast, exhibition, publication, or promotion of this program.

Yes
No

Parent/Guardian Signature

Date