21st Northern Application MSAD58 School Year

The 21st Century Kids of Northern F.R.A.N.K.L.I.N. is providing an in-person after-school program opportunity to K-8 students who attend Day Mountain Regional Middle School, Phillips Elementary, and Kingfield Elementary Schools, homeschool, and private schools.

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

Parents will receive an “application received” confirmation email within 3 business days of submission.

The program will run from September 14th until a date to be determined in June.

The program will run Monday through Thursday from 2:45-5:00.

Student's Last Name*

Student's First Name*

Gender*

Student Birthdate*

Nickname

Student Home Phone

Student Street Address

City

State

Zip Code

Student's Ethnicity*

Entering Grade 2026-2027 School Year*

Student Qualifies for:*

Students Primary Language

Child's School for 2026-2027 school year*

Which school would you like to attend the after school program at?*

Due to end of day shuttles, your child may attend a different school for ASP than the one they attend during the school day.

Student Transportation Home*

Select All
Parent/Guardian Pick Up
Walk Home/Ride Bike 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 provide your own 1:1 support please make arrangements and consult with Milissa Cousins at 207-491-9842 or mcousins@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*

Employer*

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*

Contact 2 Employer*

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*

Contact 3 Employer

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

Contact 4 Employer

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 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. 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 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. 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 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. If you do not agree, this will affect your child’s acceptance into the program.

Field Trips*

I AGREE
I DO NOT AGREE

The 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program may take walking-distance field trips during some programming hours. These field trip locations and dates will be shared with 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 MSAD58 property under supervision of the 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program Staff, Partners, and Volunteers. While taking part in these community field trips I release the 21st Century Kids of Northern F.R.A.N.K.L.I.N. After School Program from responsibility for any risk of bodily injury, death, or property damage as covered in the “General Release of Liability”.

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 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 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 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.

Parent/Guardian Signature

Parent/Guardian Signature*

Date*

1. 2026-2027 After School Program MSAD58

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