RSU73 Summer Program

How the Summer Program Runs:

The 21st Century Kids of Southern F.R.A.N.K.L.I.N. provides an in-person summer program opportunity to students entering K-8 in the 2024-2025 school year who attend Spruce Mountain Primary, Spruce Mountain Elementary, Spruce Mountain Middle School, or are homeschooled.

The program will run beginning Monday June 24th until Thursday, August 1st. The program will not be running July 4th.

Summer Program Hours are:

11:00-3:00 PM, Monday through Thursday

The summer program will run at Spruce Mountain Middle School and Elementary School.

Students who attend RSU73 Summer School are welcome to join us after their morning academics.

This application is required if you would like to be considered for the 21st Century Kids of Southern F.R.A.N.K.L.I.N. Summer Program. This application is not a guarantee that you will be selected for the summer program.

There will be no fee for this Summer Program.

The summer program will provide fun, active, and engaging outdoor and indoor activities (when necessary) designed to maximize students' physical activity and to keep their brains from slipping into the summer slide.

Attendance Requirement: If your child is accepted into the program and does not attend within the first week of programming, they will be removed from the program. Students must attend 3 out of 4 days each week to remain enrolled in the summer program.

Transportation will not be provided. All students will need to be dropped off and picked up by a parent/caregiver or their designee.

Care to join us? We hope you will!! Please fill out an application for each of your children if you'd like to be considered for the summer program. Please call Renee Whitley and Milissa Cousins with any questions at 207-778-6960 or 207-491-9842.

Parents will be notified if their child has been accepted or not within 5 business days of submission of an application.

Today's Date*

Entering Grade 2024-2025 School Year*

Student's First Name*

Student's Last Name*

Student Birthdate*

Gender*

Physical Address*

City*

State*

Zip Code*

Child's School for 2024-2025 school year*

Parent/Guardian

#1 Parent/Guardian First Name*

#1 Parent/Guardian Last Name*

Relation to Student*

Email*

Cell Phone*

Home Phone*

#2 Parent/Guardian First Name

#2 Parent/Guardian Last Name

Relation to Student

Email

Cell Phone

Home Phone

If parents are separated, who has primary residence?*

Student's Ethnicity*

Is English your child’s second language?*

Student Qualifies for:*

Does your child receive special education support services?*

Does your child have an I.E.P in place?*

If yes, for what?

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

If yes, for what?

This program is intended for students who do not have additional educational and/or behavioral supports. If your child receives 1:1 educational and/or behavioral support from the district please know that this 1:1 support does not extend to the summer program. In addition, the summer program cannot offer educational or behavioral support services. To discuss whether the summer program would be appropriate for your child, please call the Program Coordinator, Milissa Cousins at 207-778-6960.

Emergency Contact (REQUIRED)

In the case of an emergency and the parent or guardian cannot be reached, please notify:*

Relationship to Family*

Address*

City*

State*

Zip Code*

Cell Phone*

Home Phone*

Parent Pick Up/Walking Home

My child has permission to walk home from the program*

Yes
No

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 consider this carefully when deciding to allow your child to walk home.

I (or another person listed on my authorized pick-ups) will be picking up my child from the program*

Yes
No

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.

Anyone who is picking up your child must provide identification until the staff becomes familiar with that person.

Adult 1*

Adult 1 Phone Number*

Adult 2*

Adult 2 Phone Number*

Adult 3*

Adult 3 Phone Number*

You must pick up your child by 3:00PM. The program ends promptly at 3:00PM Monday through Thursday.
Pick up after 3:00pm may result in a fee of $5.00 per 15 minutes late after the first occurrence. 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. Summer Program Staff is relieved from the responsibility of looking after any child before the program begins and after the program ends when s/he has left the 21st Century Kids of Southern F.R.A.N.K.L.I.N. Summer Program.

Student Attendance

Attendance Requirement: If your child is accepted into the program and does not attend within the first week of programming, they will be removed from the program. Students must attend 3 out of 4 days each week in order to remain enrolled in the program.

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. Summer Program staff are not allowed to dispense medication to any child unless the parent/guardian completes a separate authorization form. Please see the Summer Site Coordinator for a form.

Medications

Medical Conditions

Recent Injuries

Food Allergies

Drug Allergies

Other Conditions or Diagnoses

Any Additional Information?

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

Is there anything else you would like us to know?

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 Southern F.R.A.N.K.L.I.N. Summer Program and the 21st Century Kids of Southern 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 Southern F.R.A.N.K.L.I.N. Summer 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 Southern 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 Southern 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 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 Southern 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 will affect your child's acceptance into the program.

Field Trips*

I AGREE
I DO NOT AGREE

The 21st Century Kids of Southern F.R.A.N.K.L.I.N. Summer Program may take long distance or 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. Summer 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. Summer 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 Southern 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 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. 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.

Parent/Guardian Signature

Parent/Guardian Signature*

Date*

1. 2024 Summer Application RSU73