STRENGTHENING FAMILIES FOR OVER 40 YEARS

RSU 9 Summer Application 21st Century Kids of FRANKLIN

21st Century Kids of F.R.A.N.K.L.I.N. RSU 9 SUMMER PROGRAM 2019 | Submission Deadline June 20th

We would like to invite you to join us in attending our FREE 21st Century Kids of F.R.A.N.K.L.I.N. Summer Program beginning July 1st until August 2nd, 2019. The program will run from 11:30am-4:30pm Monday through Thursday and Fridays 8:30-4:30. We will feed your child a healthy lunch from 11:30-12:00 and then they will join our 21st Century Staff for an afternoon filled with sun and fun! Transportation to the program in the morning will not be provided unless your child is a part of the Summer Learning Club. Parents will have to transport their children to the program for 11:30am. There will be a shuttle bus provided at the end of the day for the students to get transported home, if applicable, to drop off locations determined by Mt. Blue Transportation Department. There will be no transportation July 25-26th.
  • Please fill out the following information. This enrollment form is required to participate in the 21st Century Kids of F.R.A.N.K.L.I.N. Summer Program. Thank you!

    Thanks to a partnership with FCCTF and the Mt. Blue school district, there will be NO FEE for this summer program. This program is for children who are entering Kindergarten through those entering 5th grade in Cascade Brook School, Academy Hill School, G.D. Cushing School, and W.G. Mallett School.

    Summer programming runs Monday through Friday from July 1st through August 2nd starting at 11:30am until 4:30pm. Friday’s will be “Field Trip Friday’s” as we will be exploring the area and all it has to offer (Friday hours are 8:30-4:30)! Transportation to and from the school will not be provided on Field Trip Friday’s. We will not have programming on the 4th of July.

    Care to join us? We hope you will!! Please fill out an application for each of your children. Thank you! Please call 207-778-6960 with any questions.

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  • Parent/Guardian

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

  • Transportation

  • There is no guarantee that your child will be dropped at your location request. Drop off locations are pre-determined through the Mt. Blue Transportation Department. You will be contacted by us at the FCCTF with the closest possible drop off locations available.
    21st Century staff is not allowed to walk children home. The Children's Task Force is concerned with unsupervised minors walking home alone and the safety of children during this time. Please contact us at 207-778-6960 to discuss options.
  • Dismissal / Sign Out

    Please list below up to 4 adults that you would like to be able to pick your child up and/or sign your child out from the program.
  • 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 your child or call your Site Coordinator for arrangements.
  • Anyone who is picking up your child must provide a picture ID.
    • Please pick up your child on time. The program ends promptly at 4:30PM on regular summer program days.
    • If there is a situation where none of the listed individuals can pick up your child, you are to write a note or call with the name and contact information for who may pick them up.
    • Pick up after 4:30 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. Summer 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. Summer Program.
  • Anticipated Attendance

  • Please indicate the days of the week that your child is likely to attend the program.
    Please indicate your interest in your child attending any weeks of Gap Camp. There will be a short registration form for this camp released. Thank you! Registration and payment deadline July 26th.
  • I would like to reserve a spot in one of the “Gap Camps” for this school year. Payment must be paid in full at the start of your child attending the Gap Camp.
  • 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.
    If you would like to be automatically enrolled in our Fall 2019 21st Century After School Program, simply check this box. Your child’s information will be automatically entered into our database, thus ensuring them a spot in our Fall Program. This program will run Monday through Thursday from 3-5:30pm. By checking the box below, you are enrolled for the Fall and are allowing us to send you more information at the beginning of the next academic year. Information will need to be updated prior to acceptance into the Fall program.
  • Parent/Guardian Release and Liability Form

    Please read and sign the standard releases and permission forms that are required to attend the summer program. Thank you. If you do not agree, please mark below the release which you do not agree with.
    I authorize the 21st Century Kids of F.R.A.N.K.L.I.N. Summer Program and the 21st Century Kids of F.R.A.N.K.L.I.N. Summer 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 F.R.A.N.K.L.I.N. Summer Program and in conjunction with any authorized event. If you do not agree, this may affect your child's acceptance into the 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 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 F.R.A.N.K.L.I.N. Summer 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 F.R.A.N.K.L.I.N. Summer Program, its partners is binding on me and my heirs, personal representatives, and successors. If you do not agree, this may affect your child's acceptance into the program.
    As your child is enrolled in the 21st Century Kids of F.R.A.N.K.L.I.N. Summer 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. If you do not agree, this may affect your child's acceptance into the program.
    The 21st Century Kids of F.R.A.N.K.L.I.N. Summer Program will take field trips during some programming hours. These field trip locations and dates will be posted for parents and guardians. We will always return by normal dismissal time, unless we notify you in advance. I give permission for my child to leave the school Property with supervision from the 21st Century Kids of F.R.A.N.K.L.I.N. Summer Program Staff, Partners, and Volunteers. While taking part in these community field trips I release the 21st Century Kids of F.R.A.N.K.L.I.N. Summer Program from responsibility for any risk of bodily injury, death, or property damage as covered in the “General Release of Liability”.
    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 F.R.A.N.K.L.I.N. Summer Program activity for the business or publicity purposes of the program and its partners. Publicity may include posts on our “21st Century Kids of Franklin” Facebook Page (@21stcenturyfranklincounty). 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 F.R.A.N.K.L.I.N. Summer 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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