STRENGTHENING FAMILIES FOR OVER 40 YEARS

RSU73 Application

After School Program Application 2020 RSU73

  • Updated 10/1/20:

    The Franklin County Children’s Task Force has been closely monitoring updated guidance for running after-school programs in Maine. This information is current as of 10/1/20 and is subject to change in accordance with DOE, District, and CDC guideline updates.

    How the Program Will Run: (Until Further Notice)

    The 21st Century Kids of Southern F.R.A.N.K.L.I.N. will provide an all virtual after-school program opportunity to K-8 students who attend Spruce Mountain Primary, Spruce Mountain Elementary and Spruce Mountain Middle Schools.

    The program will run from October 13th until a date to be determined in June.

    Program Hours by School:

    SMMS will run Monday-Thursday 2:15-4:15pm

    SMES & SMPS will run Monday-Thursday 3:15-5:15pm

    21st Century Staff will deliver packets with materials and instructions to support any virtual meetings. There is no cost for these materials or their delivery.

    Students will be offered Tutoring, Homework Help, and engaging Enrichment Activities.

    Applications will be accepted until the program is full.

    Once the program is full, remaining applications will be placed on a waitlist.

    Parents will receive an “application received” confirmation email within 1 business day of submission.

    If your child does not attend the program for two consecutive weeks on the days indicated on their application, they may be removed from the program so that another student from the waitlist can take their program slot. Students removed from the program may be placed on the waitlist.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • 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/Parent Pick Up

  • There is no guarantee your child can be dropped off at your home address. We consult with RSU #73's transportation department to determine what drop off options are available. Please indicate your most desired drop off location. In addition, transportation availability will be determined by district policy in response to COVID-19.
    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.
  • Please list below 3 adults that you would like to be able to pick your child up and/or sign your child out from the program. Adults may be required to stay in their vehicles for drop off and pick up. Staff will chaperone students to and from their vehicle.

    Anyone who is picking up your child must provide a picture ID.

  • If there is a situation where none of the listed individuals can pick up your child, you are to call the Site Coordinator with the name and contact information for who may pick them up.
    • You must pick up your child by 4:30PM. The program ends promptly at 4:30PM Monday through Thursday.
    • Pick up after 4:30pm will result in a fee of $5.00 per 15 minutes late. This will be strictly enforced this year. Payment must be made before your child can return to program.
    • The 21st Century Kids of Southern F.R.A.N.K.L.I.N. After School Program Staff is relieved from the responsibility of looking after any child after s/he has left the 21st Century Kids of Southern F.R.A.N.K.L.I.N. After School Program.
  • Anticipated Attendance

  • Please indicate the days of the week that your child will attend the program this year.

    If your child does not attend the program for two consecutive weeks on the days indicated on their application, they may be removed from the program so that another student from the waitlist can take their program slot. Students removed from the program may be placed on the waitlist.

    Program structure may be in person, hybrid, or all virtual. 21st Century staff will follow the guidelines of RSU73 and the Maine DOE when making these decisions.
    Program structure may be in person, hybrid, or all virtual. 21st Century staff will follow the guidelines of RSU73 and the Maine DOE when making these decisions.
    Program structure may be in person, hybrid, or all virtual. 21st Century staff will follow the guidelines of RSU73 and the Maine DOE when making these decisions.
    Program structure may be in person, hybrid, or all virtual. 21st Century staff will follow the guidelines of RSU73 and the Maine DOE when making these decisions.
    Program structure may be in person, hybrid, or all virtual. 21st Century staff will follow the guidelines of RSU73 and the Maine DOE when making these decisions.
    Program structure may be in person, hybrid, or all virtual. 21st Century staff will follow the guidelines of RSU73 and the Maine DOE when making these decisions.
    Program structure may be in person, hybrid, or all virtual. 21st Century staff will follow the guidelines of RSU73 and the Maine DOE when making these decisions.
    Program structure may be in person, hybrid, or all virtual. 21st Century staff will follow the guidelines of RSU73 and the Maine DOE when making these decisions.
    Program structure may be in person, hybrid, or all virtual. 21st Century staff will follow the guidelines of RSU73 and the Maine DOE when making these decisions.
  • 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.
  • Any Additional Information?

    If there's anything else you'd like us to know, please do so below.
  • 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.
    Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a mean to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in 21st Century Kids of Southern F.R.A.N.K.L.I.N. After School Program or accessing RSU73 facilities could increase the risk of contracting COVID-19. The 21st Century Kids of Southern F.R.A.N.K.L.I.N. After School Program and RSU73 in no way warrant that COVID-19 infection will not occur through participation in the 21st Century Kids of Southern F.R.A.N.K.L.I.N. Program, or as a result of accessing RSU73 facilities. If you do not agree after reading this disclaimer, this will affect your child's eligibility for the program.
    I authorize the 21st Century Kids of Southern F.R.A.N.K.L.I.N. After School Program and the 21st Century Kids of Southern F.R.A.N.K.L.I.N. After School Program Staff to contact my child via Zoom for online learning opportunities. If you do not agree, this may affect your child's acceptance into the program.
    I authorize the 21st Century Kids of Southern F.R.A.N.K.L.I.N. After School Program and the 21st Century Kids of Southern 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 Southern 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.
    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 Southern 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 Southern 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.
    As your child is enrolled in the 21st Century Kids of Southern 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.
    The 21st Century Kids of Southern 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 RSU73 property under supervision of the 21st Century Kids of Southern 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 Southern 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”.
    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 Southern 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 Southern Franklin” 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 Southern 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

  • Date Format: MM slash DD slash YYYY