EXTENDED STUDENT SERVICES 2017-2018 ASES GRANT AFTER SCHOOL ENRICHMENT PROGRAM (Lakeside Middle School - ASES - LATER Program Only) Children Registration & Emergency Information (One form per child is required for program) Registration Emergency Information Parent Agreement Early Release Policy Student Name: DOB: / / Grade: Gender Permission for student to self-release Parent/Guardian Information: (In order of contact) Child/Children Live with: Mother Father Both Pick up or notification will be in order of contact [1] Parent/Guardian Name: Phone 1: ( ) Phone 2: ( ) Address: Optional E-mail address: [2] Parent/Guardian Name: (2) Phone 1: ( ) Phone 2: ( ) Address: Optional E-mail address: Emergency Pick-Up Information (Person(s) authorized to pick up child): [3] Name: Relationship: Phone (1): ( ) Phone (2) ( ) [4] Name: Relationship: Phone (1): ( ) Phone (2) ( ) [5] Name: Relationship: Phone (1): ( ) Phone (2) ( ) Please indicate any medical conditions that the staff should be aware of and/or that would limit your child s activities (i.e., allergies, asthma, injuries, etc.) If your child needs any medication please indicate: Name of Medication: Approx. Time of Day: Before medication is to be administered, a completed Physician s Statement form must be on file. Parent/Guardian Agreement & Liability Release: ESS Programs operate as an extension of the school day and all School Rules will be enforced during the program hours. Students receiving three (3) disciplinary notices may be suspended from their current program for up to 1 week. A fourth (4 th ) notice may result in exclusion from all ESS Programs for the remainder of the current school year, including seasonal camps. Depending on the seriousness of the incident, a single day or immediate exclusion may be enforced. The school principal will also be notified of all incidents, further school discipline may occur Students are to scan themselves into the computer at the conclusion of the school day and are to be scanned & signed out at the time of release from the LATER Program. Students authorized by parent may release themselves otherwise; students must be signed out on the daily roster by an authorized adult. Check parent files daily for correspondence & notices. If someone, is not listed on the registration form, and will be picking up your child (children), the center must receive authorization in writing prior to pick-up. Emergency information is to be updated when necessary. In signing below, you acknowledge your understanding of the district policy and legislative intent regarding early release from the LATER Programs at Lakeside Middle School according to the reasonable excuses listed on the back of this registration form. You also understand your child (children) should attend the program for the full range of hours. Children will always be released to authorized adults who sign them out early on the daily attendance sign-in sheet stating any of the acceptable reasons for release. Should a student need to leave before 5:30pm, it is mandatory that an Early Release form (back side of registration form) be on file and current at all times. Repeated violations of the Early Release policy will result in the student being removed from the FREE program and placed on the waiting list or the tuition based program. A late pick-up fee of $1.00 per minute will be charged after center closing and is due at the time of pick-up. A fourth (4 th ) late pick-up will constitute exclusion from all Extended Student Services programs. Any child not picked up by 6:30 p.m. will result in the Sheriff Department being called to pick up said child. I understand that participation in ESS Program will include outdoor activities, and all the risks that accompany such activities. In case of emergency, staff will contact parent/guardian or an emergency contact provided. If immediate hospital attention is needed, staff will call 911. I understand that I will be held responsible for all costs incurred. I therefore waive any claims and agree to release and hold harmless this program, its employees or agents. I have read, understand, and agree to abide by all of the above statements: Parent Signature LMS PROVIDES BEFORE-SCHOOL CARE FOR A FLAT RATE OF $125 PER MONTH Morning care is provided from 6:00AM to 8:20AM - The flat fee entitles your child to attend the morning program daily or as needed. YES I will need morning care NO I will not need morning care Revised April 2017 Date
2017-2018 ASES L.A.T.E.R. - Early Release Policy ASES LATER Program LMS School Hours M,T,TH,F - 3:05 p.m. - 6:00 p.m. / W - 1:05 p.m. - 6:00 p.m. ASES REQUIREMENT CODES PM - LATE ARRIVAL EARLY RELEASE WAITING LIST POLICY ASES Requirements Ed Codes ASES LATER Program TDS School Hours M,T,TH,F - 1:50 p.m. - 6:00 p.m. / W 11:50 a.m.- 6:00p.m. EC Section 8483 (a)(1) EC Section 8483 (1)(a)(1) EC Section 8483 (a)(2) The ASES Program is a grant based program offered at the Lakeside Middle School & Tierra del Sol Middle School ESS L.A.T.E.R. sites and as such, has certain state legislated regulations regarding attendance. It is the intent of the state legislations that provides major funding for Lakeside Union School District Before & After School Programs students are expected to attend the program every regular school day for the full range of program hours. Priority will be given to students who can attend full day, every day; wait list students will be given the same priority. A waiting list will be established with priority given to fulltime participants. In order for your child to be excused for being released early from the after school program, this registration must be signed and updated regularly indicating reason and duration of the authorization for early release. PARENT NAME: STUDENT NAME: Reason(s) for Requesting Late Arrival 1. Parallel Program 2. Family Emergencies 3. Family Needs 4. Medical Appointment 5. Weather Conditions 6. Medical Emergencies 7. Other Conditions 8. Transportation Middle School Students Authorization for Early Release It is the intent of the California Legislature that pupils enrolled in the after school program in middle school attend a minimum of nine hours a week. If a middle school student is unable to attend the minimum number of hours and days, the parent / guardian must complete and submit for approval, a request for early release specifying the days and hours the pupil will attend and the reason(s) for requesting early release. Priority for enrollment will be given to students who can attend the full day every day. Non-compliance with the attendance and early release policy will result in disenrollment from the after school program. Attendance and Early Release Policy In accordance with the California Education Code Section 8483(a) (1) (2) (3), the following attendance and early release regulations for the After School Education and Safety Program (ASES) are required: Date Range Example: 10/1/17-1/12/18 ER Reason 1. Parallel Program Dance Class off campus MON TUE WED THU FRI Parent / Guardian Signature Date of P/G Signature 5:15 n/a 5:15 n/a n/a 9/20/17 Program Leader Initials These policies were developed in accordance with the San Diego County Office of Education, Extended Learning Programs Unit For Office Use: Free Reduced Program Note: Revised April 2017
Lakeside Union School District Student Technology Acceptable Use Policy Students and parents/guardians agree to: 1. Engage in activities that are lawful and school-appropriate. 2. Avoid accessing, posting, submitting, publishing, and/or displaying all inappropriate material, such as those that are threatening, obscene, sexually explicit, or harassing. In addition, students will not use the system to promote the use of drugs, alcohol or tobacco. 3. Show respect for others by not engaging in cyberbullying, and reporting any cyberbullying posted on the Internet, social networking sites, or via other digital technologies such as text messaging. 4. Follow copyright laws by only using work, files, and programs to which permission has been granted. 5. Keep passwords private and secure at all times. 6. Take proper care of district equipment. Vandalism will result in the cancellation of user privileges. Vandalism includes the intentional uploading, downloading, and/or creating computer viruses and/or any malicious attempt to harm or destroy district equipment, materials, or data of any other user. 7. Report any security problems or misuse of services to the teacher, principal, or ESS staff. The principal or designee shall make all decisions regarding whether or not a user has violated these regulations and may deny, revoke, or suspend a user s access at any time. The decision of the principal or designee shall be final. Parent/Guardian Signature: Date: LUSD Photo Permission Form The Lakeside Union School District communicates with parents, students, and community members through a variety of methods. Online communications, to include the district and school websites (www.lsusd.net), Instagram (@lakesideunion) and Twitter (@LUSDInnovat_Ed), provide a convenient way to stay connected to school events, classroom learning, and important information. Photographs and/or digital recordings of students are taken periodically in the classroom or at school functions to be used in both online communications and print materials, such as class bulletins, promotional materials, and art projects. To protect student identity, student names are not used unless specific permission is obtained for a special purpose. This consent form grants the Lakeside Union School District permission to publish photos and/or student artwork. I release the Lakeside Union School District and its employees, officials, and agents from any liability of any claims, including without limitation, claims for libel, defamation, invasion of privacy and right of publicity, and infringement of proprietary rights, arising out of or relating to the exercise of rights granted under this consent and release. This permission stays in effect unless a request in writing is made to the principal or designee that access be revoked. I give permission to publish photographs of my student and for the above purposes. YES NO Parent Signature: Date: School:
LAKESIDE UNION SCHOOL DISTRICT EXTENDED STUDENT SERVICES PROGRAM LATER Sports Club 2017/2018 Information for Registration Form All prospective extramural sports participants must complete this form and provide proof of medical insurance and have a parent/guardian signature authorizing their child s participation prior to participation in any activity or practice. All students must have the sports waiver signed to participate in after school sports events, even on a one time basis. A variety of seasonal sports will be offered Mon-Fri including but not limited to the following; Flag Football, Weight Training, Cross Country, Soccer, Basketball, Track & Field, Softball CALIFORNIA LAW (Member of Athletic Team) The California Education Code (sections 32221-32224 and 49470-49474) Members of an athletic team means member of any extramural athletic team engaged in athletic events on or outside the school grounds, maintained or sponsored by the educational institution or a student body organization thereof requires that each member of an athletic team shall have insurance coverage for medical and hospital expenses in an amount of at least $10,000 while participating for or participating in athletic activities sponsored under the jurisdiction of a public school district. In order to comply with the state law, each athletic team member must be enrolled in either a Student Accident Insurance medical plan or have medical insurance coverage in an amount of at least $10,000 provided under any other type of insurance plan(s) which may have been purchased by the student or by the parent/guardian. The following information is required effective January 1, 2007 but, is provided for information only: Under state law, school districts are required to ensure that all members of school athletic teams have accidental injury insurance that covers medical and hospital expenses. This insurance requirement can be met by health benefits that cover medical and hospital expenses or students may qualify to enroll in no-cost or low cost local, state, or federally sponsored health insurance programs. INSURANCE PROTECTION (A&B) Parents/guardians must provide proof of insurance, complete and sign the following athletic waiver of insurance as evidence of insurance coverage before the student is eligible to participate in athletic events. A copy of student s proof of medical insurance (copy of medical card) will be kept on file with the LUSD LATER Program.
LAKESIDE UNION SCHOOL DISTRICT EXTENDED STUDENT SERVICES PROGRAM LATER Sports Club Registration Form 2017/2018 A: Personal Insurance Information: I hereby declare that my student, has medical insurance of at least $10,000 administered by Insurance Co.; Policy #, which will provide coverage for medical and hospital expenses resulting from accidental bodily injury while practicing for or participating in athletic events. I hereby release the Governing Board and school officials of the Lakeside Union School District from any and all responsibility to provide the insurance required under California Education Code Section 32220-32224. I WILL NOTIFY THE SCHOOL OF ANY CHANGE OR LAPSE IN THE ABOVE COVERAGE. B: Athletic Waiver: Student Name (Please Print) School: Birth Date: Grade: Address: City: Zip: Phone (Cell): Phone (Home): SPORTS WARNING STATEMENT Participating in competitive athletics may result in severe injury, including paralysis or death. Players can reduce the risk by reporting all physical problems to their coaches, following coaches instructions regarding playing techniques, training and other team rules, etc., and agreeing to obey such instructions. Even if all these requirements are met, a serious accident may still occur. PARENT PERMISSION In consideration of the permission granted, we, the undersigned, hereby RELEASE, DISCHARGE and HOLD HARMLESS the Lakeside Union School District from all liability arising out of or in connection with the identified athletic sport/activity. The release and discharge of the Lakeside Union School District from all liability includes any defect or alleged negligence attributed to the Lakeside Union School District or any of its coaches, agents, instructors, teachers or any assistants supervising, directing or instructing in the athletic sport/activity. I have read the above release. I understand and agree to its terms. I understand that all sports can involve MANY RISKS OF INJURY including, but not limited to, those risks outlined above. In the event of an accident, or sudden illness, the school district has my permission to render whatever emergency medical treatment may be deemed necessary for the above named student. I am signing this document on my own behalf, as well as on behalf of my student athlete. Signature of Parent/Guardian: Date: A copy of student s proof of medical insurance needs to be attached.
Students with Insurance: LAKESIDE UNION SCHOOL DISTRICT EXTENDED STUDENT SERVICES PROGRAM LATER Sports Club Information, Registration Form & Process for Participation for Sports Club Participation 2017/2018 LUSD Insurance Process for Sports Club Participation Parent to return signed Sports Registration Form and provide Proof of Insurance to Coach or LATER program staff. Coach or LATER Program staff checks to verify both sides of Sports Application Form are signed and a copy of Insurance coverage is included. Coach gives all forms turned to him to the LATER Director who will make copies for coach and generate a Sports Approved attendance list for the coach. LATER Director will then forward original forms to the Extended Student Services Program Manager, Jerred Murphy. FOLLOW UP: Insurance must be valid for the entire school year or during participation in the sport the student intends to participate in for the LATER athletic program. ESS will verify that students participating in the athletic programs are on the verified insurance Sports Approved attendance list. If student is not on the Sports Approved attendance list, ESS will notify Coach/Site Director and contact parent to discuss participation.