After School Learning Centers
Name of Child: _____________________________________________
Grade: _________________________
Dear Parents:
The After School Learning Center is designed to help children reach their potential. We often have a waiting
list for students who need the program. Attendance is important in our program for children to succeed. If a
student is absent more than half the days on a monthly basis the student may be dismissed from the program.
The site coordinator will notify parents if dismissal is being considered.
I have read and understand the attendance policy stated above.
______________________________________________________
Parent Signature
In case of inclement weather (snow, fog, heavy rains) it may be necessary to close the after school program
early. Please complete the following information to assist us in getting your child home safely in such cases.
__________________________________________________________ (name of child(ren) will follow the
plan below in case of early dismissal.
Please indicate the plan for your child and a phone number where you can be reached.
 My child should ride the bus home and I need to be contacted.
 My child should ride the bus home and I do not need to be contacted
 My child will be picked up by a parent and I need to be contacted.
 A parent will pick up my child and I do not need to be contacted.
__________________________________
Phone number to call if After School
closes early.
___________________________________
Parent Signature
We will cancel the program if the forecast is calling for severe weather. Students will be sent home
by normal procedures if the program is cancelled. Please give a phone number where you can be
reached between 12:00 and 3:00.
______________________________________________
Phone number (Between 12:00-3:00)
One of our goals is to continue the after school program for many years. One way we can accomplish this
goal is through promotional activities. Some of the activities include news coverage, a web page,
advertisements, and presentations. One way to promote what we do is through pictures. We need your
permission to use pictures of your child(ren) to help us promote our program.
_____ I give the After School Learning Center permission to use my child’s picture in promotional
activities.
_____ I do not give the After School Learning Center permission to use my child’s picture in
promotional activities.
______________________________________________________
Parent Signature and Date
Turn over please
Code of Student Conduct
1.
2.
3.
4.
Student behavior will allow other students to learn.
Student behavior will allow teachers to teach.
Student behavior, which is not in the student’s best interest, will be stopped.
Student behavior, which is appropriate, will be recognized through a variety of
methods by teachers, staff, and parents.
Bus Code of Conduct
1. Student will sit in a seat at all times, facing forward with feet on the floor
while the bus is moving.
2. Student will keep their hands, arms, feet, legs and head inside the bus at all
times.
3. Student will refrain from loud talking or laughter on the bus.
4. Student will obey the bus driver at all times. In an emergency, this may
mean the difference between your safety and injury or death.
If a student does not follow the code of student conduct the following consequences will occur:
First offense: Warning
Second offense: Parents will be notified
Third offense: Dismissal from Program
We ask all parents to assume an active role in school and after school performance and behavior.
Together we can look forward to a successful after school program.
As a parent, I wish to offer my support of the After School Learning Center’s Code of
Student Conduct and Bus Code of Conduct.
_____________________
Student’s name
_____ ________________________
Signature of Parent/Guardian and date
Please return this form to your Site Coordinator.