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22-23 Orleans Afterschool Enrollment Form
2022-2023 School Year
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    (Note: Hoosier Uplands staff are not allowed to administer medications of any kind.)
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    Signing this form permits Orleans Elementary School to share confidential information and work together in providing services for students that are enrolled in the Afterschool Program. I authorize the schools to exchange information relating to the above named student.  This agreement will expire on June 30, 2023.  This information will be used to develop educational profiles of your child/children.  I understand that personal records are protected by various federal and state laws and cannot be disclosed without this, my written consent, unless otherwise authorized.
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    Payment Policy

    • The Afterschool Program will operate on a prepaid basis of $5 per week per student.
    • Program hours will be 2:45 p.m. to 5:45 p.m. All students must be picked up from the program by a parent or a person designated on the departure list.
    • Students will not be eligible to attend if his/her account has a zero balance. If a student comes to the program with a zero balance, he/she will be sent to the school office and put on the bus.
    • Students that have a zero balance for more than two weeks will be dropped from the program and placed on a waiting list.
    • Payments may be made at the site location to the Afterschool Program Assistant or mailed to Hoosier Uplands main office at 500 West Main Street, Mitchell, IN 47446 Attn: Whitley Clements. Cash will not be accepted at the site!
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    For All Participants

    • I agree to give Hoosier Uplands permission to photograph my child. These photos may be used in support of the program as needed.
    • I agree to inform my child/children of the policies of this program and will insist that they abide by them while participating in the program.
    • I agree to give Hoosier Uplands permission to access and keep copies of my child’s academic records, including report cards, standardized test scores and cumulative records. This permission will extend throughout the school year. These scores will be kept confidential and only be used by Hoosier Uplands and Indiana Department of Education.
    • Hoosier Uplands is not responsible for lost or stolen items such as mp3 players, cell phones, etc.
    • Parent agrees to prepay for all afterschool services and understands that students will not be eligible to attend if his/her account has a zero balance. Students that have a zero balance for more than two weeks will be dropped from the program and placed on a waiting list.

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