ATTENDANCE ** Students are expected to attend on average 4 days per week and to be picked up

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1 x1 Wautoma Area School District STUDENT INFORMATION (1 form per child please) School: Parkside Redgranite Riverview Other: Student s Name: Date of Birth: Gender: Grade: Other students in household applying for A+: REASON FOR APPLYING (check all that apply): Time for Homework Enrichment Activities (clubs) Social/Emotional Skills Healthier Choices (physical activity/nutrition) Teacher Recommendation Adult Role Models/Mentors Safe/supervised place while I m at work Other (list) ATTENDANCE ** Students are expected to attend on average 4 days per week and to be picked up during pick-up time (4:45-5:15pm at Redgranite, 5:00-5:30pm at Parkside and Riverview.) My child will attend: Monday - Friday or Mon Tues Wed Thurs Fri or Days will vary CONTACT INFORMATION: **Guardian & Emergency Contact Info (names, phone numbers, s) will be collected through your school district registration. Primary Language spoken in the home: English Spanish Other: BEST Way To Reach You around program hours (2:30-5:45pm): Call Text Other: Are there any other specific details we should know about contacting you (i.e. ok to call at work, call 2nd contact during A+ hours, etc.): The best way to share time sensitive information with you is (for activities/field trips/payments due/etc.): Printed Materials Students Agenda Website Text Facebook Other: Return this form to Parkside, Redgranite or Riverview School s A+ Programs

2 ABOUT YOUR CHILD: Identify the top two academic goals you have for your child. Increase homework completion Decrease Late Work Improve study skills Improve organizational skills Improve reading skills Improve math skills Improve writing/speaking skills Improve spelling skills Improve Handwriting Attitude about school Improve Time Management Skills Other: Identify the top two personal/social goals you have for your child. Improve peer relationships Take responsibility for actions Make new friends Improve attitude Show respect Be more trustworthy Be more confident Be more assertive Other: Identify the top two healthy living goals you have for your child. Increase physical activity Try new activities Try new foods Maintain current physical activity Decrease screen time Improve healthy food choices Decrease sugar/sweetened beverages Self-Care/Hygiene Other: Describe/list any issues at school that make it difficult for your child to learn/excel at school? Describe/list any stress at home that may be affecting your child? What are your child s strengths, what are you most proud of, what does he/she do that makes you smile? Describe/list any other concerns or anything else you would like to share to help us when working with your child afterschool?

3 Complete this page once per family, indicate any differences for each child below if needed. PAYMENT PLAN: If accepted, I plan to pay (choose one) : $150 (Annual) due by August 31st $45(Quarterly) $80(By Semester) Other Payment Plan Needed (we will contact you to set up a plan) Any other comments: Transportation: (Check all that will be used regularly throughout the year.) Pick-Up: List up to 3 adults who can pick up your child other than the guardians & emergency contacts. (must have photo ID to show A+ staff) 1. Name: Phone Number: Relationship to child: 2. Name: Phone Number: Relationship to child: 3. Name: Phone Number: Relationship to child: Walk/Bike Home (What time? ) Ride the Late Bus -(Parkside & Riverview Students ONLY) Choose 1 drop off location below. *drop of locations are in order of bus route, i.e. if picked up at Riverview you cannot be dropped off at the High School. High School 5:30 pm Riverview 5:32 pm Mayville Engineering Corp. by storage sheds 5:34 pm Hope Lutheran Church/Bean Street 5:36 pm Intersection of Hwy 21 and 18th Avenue 5:39 pm Marion Town Hall (Spring Lake) 5:47 pm Click Campers on Hwy 21 5:52 pm Redgranite Park 5:55 pm Mount Morris Community Center 6:04 pm Should your student WALK home when they are dropped off by the late bus? YES NO If NO, who will pick up your student at the drop off location marked above? Name: Phone Number: Relationship to student:

4 ABOUT THE PARENTS/GUARDIANS/FAMILY: (complete once per family only) What skills or interests do you have that you would be willing to share with kids or other parents? (examples: share about your job or give a tour at your work, teach a skill (painting/sign language) or present a topic (animal care, internet safety, etc.). Rate your interest in attending each of the following family/parent enrichment topics below. TOPIC YES! MAYBE/ DEPENDS NO PARENTING SKILLS/TOPICS: YES! MAYBE/ DEPENDS NO Mental Health topics Helping your child with homework. Financial Planning/Budgeting Teaching decision-making skills Fitness/Physical Activities Handling Stress Nutrition/Meal Planning Love & Logic Parenting Navigating school info/ Infinite Campus Positive Communication Computer Skills/Training Nurturing Parenting Routines Foreign Language (Sign, Spanish, etc.) Dealing with inappropriate behaviors Career Change/Job Skills Developing Family Rules GED (if you do not have a h.s. diploma) Parent Support Group English Classes for non-native speakers Holding Family Meetings Student College & Career Readiness Personal Power for Parents & Children Community Service Projects Behavior Management Field Trips with your child Appropriate Rewards & Consequences Family Fun Nights Appropriate Ways of Handling Anger Hobbies/enrichment for adults/families. Teaching problem solving skills. (examples: painting, fishing, cooking, etc.) Other: Other: The learning styles that work best for me/that I prefer are? Presentation/Lecture Small group Webinars/online Handouts/reading Hands-on Other: The best time of the year for me to attend is: (mark all that apply) Fall Winter Spring Summer Other: The best day of the week for me to attend is: (mark all that apply) Mondays Tuesday Wednesday Thursday Friday Saturday Sunday The best time of the day for me to attend is: (mark all that apply) 6-8am 8am-Noon Noon - 4pm 4-6pm 6-8pm Other: Are you interested in being on a Parent Advisory Committee to help A+ better meet parent and family needs, improve quality and plan for sustainability? (meet 1-4 times per year). Yes No

5 A+ FAMILY AGREEMENT (one per family needed) The A+ Program engages youth in a variety of enrichment programs that promote positive youth development and enhance academic skills in a safe supportive environment. ATTENDANCE/PICK-UP: REGULAR ATTENDANCE IS IMPORTANT Students are expected to attend and stay for the entire duration of the program each day (4 days per week on average). Failure to do so may result in suspension from the program. Parkside & Riverview pick-up times: 5-5:30pm Monday - Thursday, 4:30-5:30 on Fridays. Redgranite pick-up times: 4:45-5:15pm Monday - Thursday, 4:15-5:15pm on Fridays. Any changes in the child s attendance schedule/pick-up must be communicated prior to 2pm that day. Students must be signed out each day by the parent/guardian or an adult from the approved pick-up list. PROGRAM OPERATION: Participation in the program is a privilege. Students must follow the rules and expectations of the program. School rules and policies apply. Unsafe, disruptive or disrespectful behavior may result in suspension or dismissal from the program. The afterschool program will not be available on days school is closed or early closings due to inclement weather. I give my consent to the A+ After School Program to: Take my student s photograph or video to be used for activities and program promotion. Access my child s school district records for the purpose of providing educational support. Call for a public emergency vehicle, if necessary, for transportation to an emergency facility. I will be responsible for any transportation charges and medical expenses. Show G and PG rated movies to my child. Administer surveys to my child to evaluate the program and to identify specific needs and personal goals. ACADEMIC SUPPORT: It is the student s responsibility to be prepared for homework time and use homework time wisely. Students may not finish all of his/her homework during A+, parents are encouraged to review homework with their child each day. A+ team members will not be able to check every problem and assignment for every child for correctness and completion each day. Student s are expected to participate in enrichment activities each week that will add to student s learning and personal development. FAMILY ENGAGEMENT: Adult family members will be engaged in the child s program experience by participating in at least two A+ After School events or support activities. Adult family members will provide feedback to the program by completing a mid-year survey and end of year survey about the A+ Program. I have read and understand the basic information on the application and family agreement and I will go over them with my child to make sure they are understood. I have read and understand the expectations, rules & policies in the family handbook. Parent/Guardian Signature: Date: Links to print the following documents can be found on the A+ Website: wautomasd.org/a-program/application-and-registration *Family handbook, family agreement, student expectations

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