LWAS Registration Form - LearningWorks

LearningWorks Afterschool is pleased to offer elementary students in select Portland, South Portland, Biddeford, and RSU 57 schools a free and fun afterschool enrichment program that will increase your student's academic self-confidence, while helping them improve their math and reading skills. Apply today to see if your student is eligible!

School Info

What school does the student attend?*

Who is the classroom teacher that is referring this student?

Please note that LWAS will check with your child's teacher to confirm that your child is eligible for the program.

School ID number (if known):

Student Eligibility

Is this student partially proficient or not proficient in math and/or reading? Please provide this student's most recent NWEA scores for math and reading.

Student Info

Student Name (Last, First):*

Gender Pronoun:*

she/her
he/him
they/their

Date of Birth:*

Home Address:*

Street Address Address Line 2 City State ZIP Code

Parent/Legal Guardian Info

Primary Parent/Legal Guardian Name:*

Primary parent/guardian relationship to the student:

Primary parent/guardian home 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?*

Call
Text
Email

Does the student's primary contact need an interpreter or translator when contacted?

Yes
No

If so, what language?

Student Technology

If your student wishes to participate in remote-only activities this summer, we'd like to know a bit more about their technology access at home, so we can provide them with tools if needed.

Does the student have access to a computer or tablet they can use at home to join their class and program activities online?

Yes, a tablet (i.e., iPad)
Yes, a Chromebook
Yes, a laptop
No, a device is needed for this student

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

Yes
No

Medical Needs

If a student needs access to prescribed or over-the-counter medication during program hours, the student's parent or legal guardian should the school's LWAS Site Coordinator for further information. Some of our sites have access to Epi-Pens and inhalers, others do not.

Please list the student's medical needs and/or allergies:*

If the student has no known medical needs, please type "no known medical needs."

Does the student carry an Epi-Pen?*

Yes
No

Does the student carry an inhaler?*

Yes
No

Emergency Contact Name (other than parent or caregiver):*

Emergency Contact Phone Number:*

Transportation

For our summer program, transportation from and to home is provided upon request for eligible students. Some students may need to walk up to a half-mile home from corner bus stops. The school's LWAS site coordinator will contact caregivers with bus details for eligible students.

Will this student need bus transportation to or from home?

Yes, my child will need a bus to and/or from the program
No, my child is within walking distance
No, my child will be dropped off and picked up by an authorized adult

Who is authorized to pick up the student?

Please list the full names of all adults that are authorized to pick up your child.

Program Releases + Consents

Online Privacy Notice + Consent to Virtual Learning

In order for LearningWorks Afterschool to provide your child with the most effective 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 interactive online and video remote learning offerings. LearningWorks Afterschool uses several computer software apps and web-based services operated by third parties, including Google Apps for Education, Seesaw, Zoom, NearPod, Kahoot!, and Flipgrid, and the operators of any additional web-based educational programs and services which LearningWorks may decide is necessary during the program 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' programs and activities, including information pertaining to LearningWorks AfterSchool;

✔ LearningWorks will not grant my child access to any website account managed by LearningWorks AfterSchool unless I provide them with permission below;

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

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

✔ I understand that by opting out of LearningWorks’ collection and use my child’s personal information, my child will not be able to participate in some LearningWorks AfterSchool activities and assignments.

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

Signature:*

A parent or legal guardian must sign this section in order for their student to be considered for this program.

Photograph + Media Release

I give LearningWorks permission to use my child’s name, likeness and speech in any audio tape, video tape, film or photo 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 claims arising out of web publication, broadcast, exhibition, publication, or promotion of this program.

YES, I agree
NO, I do not agree

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 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 my student's school district. I give permission for LearningWorks to use this information for required grant reporting and to coordinate services with the school district and LearningWorks staff.

Signature:*

A parent or legal guardian must sign this section in order for their student to be considered for this program.

Filling out this form does not guarantee your student a place in the program. Acceptance to the program is subject to your student's eligibility, and the availability of open slots. Please allow 5-7 business days for your application to be processed.