21st Century Kids Application for RSU 9

The 21st Century Kids of F.R.A.N.K.L.I.N. is providing an after-school program to K-5 students who attend Cushing School, Academy Hill School, Cascade Brook School, W.G. Mallett, homeschool, and private schools. The after school programs will be located at W.G. Mallett School and Academy Hill School.
The program will run from September 16th until a date to be determined in June.
The program will run Monday through Thursday from 3:15-5:15. There will be no program on Fridays.
You will receive an “application received” e-mail within 3-5 days of submitting your application.
You will be notified of your child’s acceptance, denial or wait listed status into the program and their designated cohort by September 9th. Students who have been on previous waitlists for our after-school or summer programs will have first prioritization on being selected.
Student's Last Name*
Student's First Name*
Gender*
Student Birthdate*
MM slash DD slash YYYY
Nickname
Student Home Phone
Student Street Address
City
State
Zip Code
Student's Ethnicity*
Entering Grade 2024-2025 School Year*
Student Qualifies for:*
Students Primary Language
Child's School for 2024-2025 School Year*
Student Transportation Home*
- Select All
- Parent/Guardian Pick Up
- Walk Home/Ride Bike Home
We currently do not have shuttle bus transportation home. 21st Century staff are 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.
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 make arrangements, please reach out to Drew Blanchet at 207-778-6960 or dblanchet@fcctf.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
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 F.R.A.N.K.L.I.N. After School Program and the 21st Century Kids of 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 F.R.A.N.K.L.I.N. 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 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 F.R.A.N.K.L.I.N. 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 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. 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 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 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 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.
Parent/Guardian Signature
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY

1. 2024-2025 After School Program RSU9

Contact Information for Parents, Guardians, and Emergency Contacts

Additional Information

Parent/Guardian Release and Liability Form

Parent/Guardian Signature

Contact Us

(207) 778-6960