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22-23 Mitchell Afterschool Enrollment Form
2022-2023 School Year
17Questions
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    List 2 alternates for us to contact in the event that the parents cannot be notified. A minimum of 1 person other than parent/guardian is required.   
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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 Mitchell Community Schools to share confidential information and work together in providing services for students that are enrolled in the 21st Century Community Learning Centers Program.  I authorize the school 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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    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.
    • I understand that priority will be given to students with academic need, working parents, and free/reduce lunch status; however, any student that is enrolled in Mitchell Community Schools is able to apply for the program.
    • I agree that students that are accepted in to the program will be required to attend at least 3 days per week and stay until 4:15 P.M.

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