21st Century RSU10 – Franklin County Children Task Force

The 21st Century Kids of the Western Foothills provides an after school program opportunity to K-8 students who attend Rumford Elementary School, Meroby Elementary School, homeschool, and private schools within the district. Soon to be included Mountain Valley Community School in 2026.

The program will run 4 days a week (Monday through Thursday) beginning September 8th, 2025 until tentatively June 4, 2026.

Program Hours by School:

The program runs Monday-Thursday from 2:30 until 5:00pm.

Parents/guardians picking up students must pick up by 5pm at each school. Transportation will be provided to students who sign up, the bus will depart at 5:00pm.

Students are offered Tutoring, Homework Help, and engaging Enrichment Activities.

Students must attend the program 3 days per week.

Parents who complete an application will be confirmed via email within 3 business days.

After you submit an application successfully, you will receive an online confirmation of your submission. You are highly encouraged to take a screen shot of that confirmation for your own records. If you do not receive an email confirmation as described above, please contact the Program Coordinator, Crystal Buotte at 207-418-4088 or cbuotte@rsu10.org

Student's Last Name*

Student's First Name*

Gender*

Student's Birthdate*

Nickname

Student's Home Phone

Student's Street Address

City

State

Zip Code

Student's Ethnicity*

Entering Grade 2025-2026 School Year*

Student Qualifies for:*

Student's Primary Language

Student's School for 2025-2026 school year*

Student Transportation Home*

Select All
Ride Bus
Parent/Guardian Pick Up
Walk Home/Ride Bike Home

21st Century staff are not allowed to walk children home. Expectations for students’ behavior on the after school program bus is the same as it is for the regular bus. RSU 10 Transportation Department’s drivers and Director have sole discretion regarding consequences for any student whose behavior does not meet expectations. If a student loses their after school program bus privileges, in most cases they are still allowed to attend the after school program, however, they will need to picked up by a parent, caregiver or other authorized adult.

You must provide a student drop off address in this form to be shared with RSU 10 Transportation Department in order to ride the After School Program bus home at the end of the day. Students will be dropped at the designated address you provide.

Does your student require transportation?*

Student Drop Off Address

Student Lives With*

Does your child receive special education support services?*

Special Education Description*

Please describe the special education supports your child receives.

Does your child require the services of a 1:1 educator?*

This program is intended for students who do not have additional educational supports. If your child receives 1:1 Educational Support from the district please know that this 1:1 support does not extend to the after school program. The program is not able to provide 1:1 support, however, parent/guardians may make their own arrangements for 1:1 support for the after school program. If you’d like to provide your own 1:1 support please make arrangements and consult with Crystal Buotte 207-418-4088 or cbuotte@rsu10.org.

Student Medical Needs/Allergies*

Please list any student medical conditions, needs, medications, allergies, diagnosis that we need to be aware of.

Teacher Last Name*

Teacher First Name*

Contact Information for Parents, Guardians, and Emergency Contacts

You have the opportunity to input information for up to 4 contacts. In each contact, you will need to tell us whether that contact is a parent/guardian, emergency contact, etc. Three contacts are required, one is optional.

Contact 1 Last Name*

Contact 1 First Name*

Email*

Home Phone*

Work Phone*

Alternate Phone*

Authorized to Pick Up Student?*

Student Lives with Contact 1?*

Is Contact 1 an Emergency Contact?*

Is Contact 1 a Parent/Guardian of the Student?*

Relation to Student*

Contact 1 Street Address*

City*

State*

Zip Code*

Contact 2 Last Name*

Contact 2 First Name*

Email*

Contact 2 Home Phone*

Contact 2 Work Phone*

Contact 2 Alternate Phone*

Authorized to Pick Up Student?*

Student Lives with Contact 2?*

Is Contact 2 an Emergency Contact?*

Is Contact 2 a Parent/Guardian of the Student?*

Relation to Student*

Contact 2 Street Address*

City*

State*

Zip Code*

Contact 3 Last Name*

Contact 3 First Name*

Email*

Contact 3 Home Phone*

Contact 3 Work Phone*

Contact 3 Alternate Phone*

Authorized to Pick Up Student?*

Student Lives with Contact 3?*

Is Contact 3 an Emergency Contact?*

Is Contact 3 a Parent/Guardian of the Student?*

Relation to Student*

Contact 3 Street Address*

City*

State*

Zip*

Contact 4 Last Name

Contact 4 First Name

Email

Contact 4 Home Phone

Contact 4 Work Phone

Contact 4 Alternate Phone

Authorized to Pick Up Student?

Student Lives with Contact 4?

Is Contact 4 an Emergency Contact?

Is Contact 4 a Parent/Guardian of the Student?

Relation to Student

Contact 4 Street Address

Contact 4 City

Contact 4 State

Contact 4 Zip Code

Any Additional Information?

If there’s anything else you’d like us to know, please do so below.

Is there anything else that would be important us to know about your child or your family?

Example: additional authorized pick ups, child likes/dislikes, etc.

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.

For Emergency Treatment*

I AGREE
I DO NOT AGREE

I authorize the 21st Century Kids of the Western Foothills After School Program and the 21st Century Kids of the Western Foothills 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 the Western Foothills After School Program and in conjunction with any authorized event. If you do not agree, this will affect your child’s acceptance into the program.

General Release of Liability*

I AGREE
I DO NOT AGREE

I hereby assume full responsibility for any risk of illness, 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 the Western Foothills 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 the Western Foothills After School Program, its partners is binding on me and my heirs, personal representatives, and successors. If you do not agree, this will affect your child’s acceptance into the program.

Release of Records*

I AGREE
I DO NOT AGREE

As your child is enrolled in the 21st Century Kids of the Western Foothills 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. If you do not agree, this will affect your child’s acceptance into the program.

Photo/Media Release*

I AGREE
I DO NOT AGREE

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 the Western Foothills 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 Franklin” Facebook Page (@21stcenturyfranklincounty) or “Franklin County Children’s Task Force” Facebook Page. 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 the Western Foothills 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.

Permission to Walk Home from Bus Stop*

I AGREE
I DO NOT AGREE

I hereby consent to allow my child to walk home from their designated bus stop unaccompanied by a parent, caregiver or other authorized adult. I realize there is potential risk for the child in walking home alone and release RSU 10 and the Franklin County Children’s Task Force’s 21st Century Kids of the Western Foothills After School Program from any legal responsibility or liability for any harm that may result to my child during the act of walking home unaccompanied from the designated bus stop. If your child is under 2nd grade, they must have a parent or older sibling above the age of 13 accompany them.

Parent/Guardian Signature

Parent/Guardian Signature*

Date*

1. 2025-2026 After School Program RSU10

Contact Information for Parents, Guardians, and Emergency Contacts

Any Additional Information?

Parent/Guardian Release and Liability Form

Parent/Guardian Signature

Contact Us

(207) 778-6960