AfterSchool Application - LearningWorks

School Info

What school does the student attend?

Biddeford Primary School
East End Community School
JFK Memorial Kindergarten Center
Kaler Elementary School
Ocean Ave. Elementary School
Presumpscot Elementary School
Reiche Community School
Rowe Elementary School
Skillin Elementary School
Talbot Community School
Waterboro Elementary School

What learning model is this student participating in this year?

Fully in-person, at school
Hybrid (half in-person, half remote)
Fully remote

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 (First + Last)*

Fall 2020 Grade Level*

Gender

Date of Birth

Address*

Street Address Address Line 2 City State ZIP Code

Primary parent/legal guardian name*

Primary parent/guardian relationship to the student

Primary parent/guardian phone number

Primary parent/guardian cell number (if different from home number)

Primary parent/legal guardian email address

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

What is the best way to reach the student's parent/legal guardian with non-emergency information?

Text
Call
Email

Does the student's primary contact need an interpreter/translator when called?

Yes
No

If so, what language?

Technology

Since we are conducting our program remotely to start this fall, we'd like to know a bit more about this student's technology access at home, so we can provide them with tools if needed.

Does the student have access to a working device at home they can use to access the program?*

Does the student have access to Wi-fi or internet at home?*

Yes
No

Medical Needs

In the event that we offer this program in-person later this fall, if student needs access to meds during program hours, the parent/legal guardian should 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 of the student's known medical needs and/or allergies:

Does the student carry an Epi-Pen?

Yes
No

Does the student carry an inhaler?

Yes
No

Emergency contact (other than primary parent)

Emergency contact phone number

Transportation

In the event that we offer this program in-person later this fall, transportation home is provided upon request for eligible students. Some students students may need to walk up to a half-mile home from corner bus stops. The LWAS site coordinator will contact caregivers with bus details for eligible students.

Is the student's caregiver requesting bus transportation?

No, the student is attending remotely

Who is authorized to pick up the student?

PROGRAM RELEASES + CONSENTS

Online Privacy Notice + Consent to Remote Learning

In order for LearningWorks Afterschool to provide your child with the most effective remote learning experience, we need to abide by the rules of the Children’s Online Privacy Protection Act (COPPA) that require parental permission as outlined below.

COPPA requires that we gain verifiable consent for your child to participate in our interactive online and video remote learning program offerings. LearningWorks Afterschool uses several computer software apps and web-based services operated by third parties, including Google Apps for Education, Seesaw, Zoom, and Flipgrid, and the operators of any additional web-based educational programs and services which LearningWorks may decide is necessary during the upcoming academic year.

In order for your child to use our educational program and services, certain basic personal information -- your child’s name, username, email address, geolocation, IP address, and video recordings of your child’s interactions with LearningWorks Afterschool staff -- must be collected, used, and/or disclosed by us. We are asking for your permission to collect, use, and disclose your child’s personal information for the purpose of monitoring your child’s program participation, collecting assignments and projects submitted online, interacting with your child online, and promoting the LearningWorks Afterschool program and its partners.

Please review the following statements regarding your rights before giving your consent:

◎ Website accounts managed by LearningWorks provide access to content, materials, and resources relating to LearningWorks's programs and activities, including information pertaining to LearningWorks Afterschool;

◎ LearningWorks will not grant your child access to any website account managed by LearningWorks Afterschool unless you provide us with permission below;

◎ You can contact LearningWorks Director of Programs Jessica Moninski at (207) 775-0105 ext. 133 to ask for the opportunity to review your child’s personal information collected by LearningWorks and have the information deleted;

◎ You have the right to opt out of any further use or collection of your child’s personal information by LearningWorks by contacting Jessica Moninski at (207) 775-0105 ext. 133; and

◎ You understand that by opting out of LearningWorks’ collection and use your child’s personal information, your child will not be able to participate in some LearningWorks Afterschool remote learning activities and assignments.

By signing this form below, you certify that you consent to the collection, use and/or disclosure of your child’s personal information as described in this Privacy Notice.

PARENT/GUARDIAN MUST SIGN FOR PROGRAM PARTICIPATION (type your name below):

Parent/Legal Guardian Signature: Online Privacy + Consent:*

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

Program Consent + Waiver of Liability

 I give permission for my child to attend LearningWorks Afterschool.

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

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

 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 here-in. 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 Public Schools (PPS) and its partners is binding on me and my heirs, personal representatives, successors, and assigns.

 I give permission for LearningWorks to collect student information on my child (academic progress, assessment data, behavior, free/reduced lunch status, special services, student ID number, and behavior) from PPS. I give permission for LearningWorks to use this information for required grant reporting and to coordinate services with PPS and LearningWorks staff.

PARENT/GUARDIAN MUST SIGN FOR PROGRAM PARTICIPATION (type your name below):

Parent/Guardian Signature: Program Consent + Waiver of Liability:*