Farrell & Sharon City School Districts
21st Century CCLC C.O.O.L.	2019-2020 Enrollment Form (Please complete both sides of this form. Please print unless otherwise indicated.)

Program Acceptance and Enrollment
By completing this application I understand that it does not guarantee immediate enrollment in the COOL program. I understand that enrollments are prioritized based on various eligibility criteria. If your child is selected for enrollment, you will receive a letter notifying you of your child’s acceptance and start date with the C.O.O.L. Program. That letter will include parent and student information for your student’s C.O.O.L. participation.

Student Information

Student Name: _________________________________ Birth date: _____________________ Grade___________ School Attending: ___________________Homeroom Teacher_____________________
Race: __Alaskan __Asian __African American __Bi-Racial __Hispanic/Latino __Native American __Pacific Islander __White

Parent(s)/Guardian(s) Name: ____________________________________________________ Home Address: ________________________________________________________________
Home Phone: __________________________ Alternate/Work Phone: _________________________ Parent Email to be used for weekly communication: _______________________________________

Emergency Contact
In the event of an emergency we will attempt to contact the parent/guardian. If we are unable to reach you, we ask that you provide an emergency contact.

Name: __________________________________ Relationship: ___________________

Address: __________________________________ Phone: ______________________

Medical/Emergency Information

Does your child have any allergies, physical or emotional conditions that our C.O.O.L. staff should be aware of? _____Yes _____ No	If Yes, please explain

Is your child currently taking prescribed medication? _____Yes _____ No If Yes, please explain:

**The C.O.O.L. staff is not authorized to dispense medication. Please make alternate arrangements if your child requires medication during the C.O.O.L. program.
My child’s Health Insurance is provided by: _____ My Health Insurance
______ School Insurance

Family Physician: _____________________________ Phone: ____________________

Insurance Provider:___________________________ Policy/Group Number:_________________________

In case of an accident, injury or illness, I hereby authorize the responsible school person to take my child to a physician or hospital emergency room, and I further understand that I will be responsible for all costs associated with said accident, injury or illness.

Please note: Bus service is free and student(s) will be dropped at neighborhood drop sites.

____I will provide transportation for my child.

____My child has permission to walk home.

____My child will need to be included for bus services.

Please identify persons approved to pick up student at the C.O.O.L. program or at Bus Stop (in addition to parent/emergency contact person).

Name__________________________________ Phone#_________________________________ Approved for bus/school pick up? YES or NO

Address_____________________________________________ Relationship___________________________________________

Name_____________________________________ Phone#____________________________________ Approved for bus/school pick up? YES or NO

Address____________________________________________ Relationship_________________________________________

Internet Usage Authorization
Use of technology is an integral part of many of our programs. Supervised activities involving use of the Internet are included. Casual e-mail and use of chat rooms will be prohibited.
Field Trip Authorization Our program will involve field trips and we will utilize transportation provided through a local bus company and district owned vans. For out of town field trips, specific advance notice will be provided and permission slips required prior to the scheduled trip.
Photographic, Digital Image and Video Release The Sharon City/Farrell Area School Districts and the 21st Century COOL program and its partners and affiliates may photograph or videotape (in any media) my child’s image, likeness, or depiction. I understand that the entities may use such photographs or images with or without associating name thereto.

PARENTAL CONSENT: My son/daughter has permission to enroll in the C.O.O.L. program Monday through Thursday. If accepted for enrollment, my student commits to attending daily unless I provide an excuse. I verify that information contained in this application is true and correct. I agree to provide a current phone number and contact information and will notify C.O.O.L. staff immediately if any information changes. I give permission for the release of necessary information for coordination of services with COOL community partners. I authorize participation of supervised internet usage, transportation by contracted carriers for off-site visits and for photos and images to be taken of my child during the program.

Parent/Guardian Signature: ________________________________________________Date: ___________________

Student Signature: _______________________________________________________Date: ___________________

Office Use Only:(please do not write in this box)
(circle all that apply) Grade:_______ Teacher/Room #:______________________Meets income eligibility: Y N

Needs:	Homework Tutoring: R M	Attendance/Tardy Behavior Social/Familial	IEP ( PSSA Scores: Read_________ Math_________)
Accept Pack Mailed:	/	/	Target Start:	/	/	School ID #__________________________

Funded in full or in part with a grant provided by the Pennsylvania Department of Education