STRENGTHENING FAMILIES FOR OVER 40 YEARS

21st Northern Application MSAD58 School Year

The 21st Century Kids of Northern F.R.A.N.K.L.I.N. MSAD 58 After School Program

JOIN US FOR THE 2019-2020 AFTER SCHOOL PROGRAM. Enrollment Form for Session Beginning: Monday September 23rd, 3:00-5:30 PM
  • Please fill out the following information. This enrollment form is required to participate in the 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program. Thank you!

    The 21st Century Kids of Northern FRANKLIN After School Program runs Monday-Thursday 3:00-5:30 at Strong, Phillips, and Kingfield Elementary Schools.

    Thanks to a partnership with FCCTF and the MSAD58 school district, there will be NO FEE for this after school program. This program is for children who are entering Kindergarten through those entering 8th grade in Strong Elementary, Phillips Elementary, and Kingfield Elementary Schools. If your child attends a private school or is home schooled within the MSAD #58 district coverage area, you are also welcome to apply!

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  • Parent/Guardian

  • This program is intended for students who do not have additional educational supports. For program admission, preference will be given to students who are not receiving additional supports. To see if your child qualifies, please call our office at 207-778-6960.
  • Emergency Contact (REQUIRED)

  • Transportation

  • Dismissal / Sign Out

  • My child may be picked up by the following adults, please list all names (for students’ safety reasons, the program policy will allow students to be released only to the adults listed below): If someone whom is not listed is going to be picking up the student, please send a note with the student to the After School Program.
  • Anyone who is picking up your child must provide a picture ID.
    • Please pick up your child on time. The program ends promptly at 5:30PM on regular program days.
    • If there is a situation where none of the listed individuals can pick up your child, you are to write a note with the name and contact information for who may pick them up.
    • Pick up after 5:30 pm will result in a fee of $5.00 per 15 minutes late. This will be strictly enforced this year.
    • The 21st Century Kids of F.R.A.N.K.L.I.N. After School Program Staff is relieved from the responsibility of looking after my child after s/he has left the 21st Century Kids of F.R.A.N.K.L.I.N. After School Program.
  • Anticipated Attendance

  • Please indicate the days of the week that your child is likely to attend the program.
  • Health/Medical Information

  • For the safety and best care of your child, please check below for any of the following that apply to your child, and provide as many details as possible.
  • Parent/Guardian Release and Liability Form

    Please read and sign the standard releases and permission forms that are required to attend the after-school program. Thank you. If you do not wish to agree, please mark below the release which you do not agree with. If I did not check “Do Not Agree” under any of the agreements listed below, I understand that this means the Franklin County Children’s Task Force knows that I do agree with all of the following statements.
    I authorize the 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program and the 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program Staff to arrange for transportation in case of accident or acute illness of the participant. It is understood that every effort will be made to contact the parents or other priority person before treatment is given but that treatment will not be withheld if a parent cannot be reached. In the event it is not possible to receive instruction for the participant’s care, consent is given to any EMS or licensed physician for treatment. I allow the EMS staff and/or physician to administer medication and to perform necessary treatment for the preservation of the participant’s health and well-being. I understand that any cost incurred for treatment of sudden illness or accident shall be paid by me. This authorization and consent for treatment is given to the 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program and in conjunction with any authorized event.
    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 hereon. I understand that this program includes physical activity 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 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program, their partners, directors, officers, employees, agents, and volunteers from any and all claims that may result from any action for damages, included 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 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program, its partners is binding on me and my heirs, personal representatives, and successors.
    As your child is enrolled in the 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program, funded by Maine Dept. of Education through funding from the US Dept. of Education our use of this funding requires that we report certain results to the Maine DOE & U.S. DOE including free and reduced lunch status, special services, academic progress, student MEDMS (school identifier) number, attendance, discipline, behavior, surveys, activity participation, and classroom performance. In addition to compliance with reporting requirements, use of this data assists program managers to make 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 and additional funding to operate this program. All information collected will be restricted and used solely for serving student needs and approved program evaluation purposes.
    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 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program activity for the business or publicity purposes of the program and its partners. Publicity may include posts on our “21st Century Kids of Northern Franklin: Msad58” Facebook Page (@21stnorthernfranklin). We encourage you all to “like” us on Facebook to get the latest updates regarding the program. I understand that any participation offers no remuneration and that my child’s name, likeness, and speech may be edited, produced, recorded for distribution throughout the United States and abroad. I expressly release the 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program and its licensees, assignees, affiliates and successors from any privacy, defamation, or other partners have arising out of broadcast, exhibition, publication, or promotion of this program.
  • Signature

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  • We will be in contact with you shortly to confirm your child's enrollment in the 2019-2020 21st Century Kids of Northern FRANKLIN After School Program.

    If you have any questions in the meantime, please call 207-778-6960.