ASP Registration and Babysitting Course Registration

March 6, 2017
Dear 5
th-8th Grade Students,

The Afterschool program is thrilled to offer you a FREE babysitting course! This basic childcare training, adapted from the Red Cross program, will be taught by Erica Owen, R.N. The class is designed to give you the basic safety skills and confidence needed to care for younger children. The class will run for 4 sessions over the course of 2 weeks: Tuesday and Wednesday, March 21 and 22 and Tuesday and Wednesday, March 28 and 29. All classes will begin at 3:15 (after a recess and a snack) and end at 4:30. Students who successfully complete the course will receive a certificate. To participate you must commit to all four sessions. It’s strongly recommended that you also sign up for CPR/First Aid which will be offered in the following weeks (please see afterschool program calendar for details).

Please fill out the bottom part of this letter and return to school as soon as possible. You need to be registered with the afterschool program to attend.

Questions? Please call or email Zoe Gascon, Afterschool Program Coordinator at 802-535-7475 or

Thanks and hope to see you at Afterschool! Sincerely,

Babysitting Course Registration:

Student’s name: ____________________________________________________________________ 

I commit to participation in all 4 classes, March 21, 22, 28 and 29.

Student signature:__________________________________________________________________


 Burke ASP Student Registration Form 2016 (printable)

Kingdom Afterschool Programs                                                                                  Student Registration Form



Student Name:  __________________________________ DOB: _________ Grade: ________ Gender: _________   


School: ______________  Parent/Guardian Name: ____________________________________________________


Address:  ___________________________________ City:  ___________________  State: ______ Zip: _________


What are the best numbers to call between 2:45 and 5:00 p.m.?


Work: ______________________Home:  ___________________            Cell:  _______________________________


Other Parent/Guardian Name:  __________________________ Phone:  _____________________________


In case of an emergency, illness or disciplinary action, please list two other persons who have permission to pick up your child:


Name:  _________________________  Phone #:  ________________  Relationship to Student: _________________

Address:  ________________________________________________________________________________________


Name:  _________________________  Phone #:  ________________  Relationship to Student: _________________

Address:  ________________________________________________________________________________________


Health Information

Does your child have any allergies or health conditions we should be aware of?  ________________________________



Student Learning Needs:  IEP _____ 504 _____ What does your child need help doing?______________________




The Afterschool Program follows the school policies and procedures; please refer to the school handbook for further information.


Required Sign out for your child:  The parent/guardian and all persons authorized by the parent/guardian to pick up their child from Afterschool must sign the child out on the form maintained by afterschool staff.  Students will be released to authorized persons only.  If staff doesn’t know the person picking up, the individual will be asked to show a photo ID to confirm their identity.  If a parent/guardian wishes to add another driver to the authorized student pick up list during the course of the school year, they will need to sign and date another form listing drivers authorized to pick up their child.

Parents/guardians are required to sign the following release as part of the Kingdom Afterschool registration process:  “By my signature below, I understand that I waive the right to hold the school/CNSU Kingdom Afterschool Programs responsible for the actions of the authorized drivers listed below”. 


Parent Signature                                                                                                                    Date




























Parent Releases:


Yes / No          I grant the Kingdom Afterschool Program and its affiliates the permission to use and/or publish photographs and videos of the above-named child in print or online for the purposes of celebrating and promoting the achievements of participants in the program.


I understand that certain risks are inherent in the types of activities in which my child will be participating.  I hereby waive all claims against Kingdom Afterschool Program employees, subcontractors, and collaborating organizations in connection with injury or illness of my child.  In case of medical emergency, if I cannot be reached, I authorize my child to be transported to and treated at the nearest hospital at my expense.


Inclement Weather Procedures:

If school is cancelled, the Afterschool Program is cancelled.  The Afterschool Program may be closed on a day that school is open due to poor weather forecasted for later that afternoon.  Parents/guardians will be notified by approximately noon by the school electronic message system or a phone call.  All students will be sent home by bus unless the school is given other instructions.




First Child

Second Child

Third Child

Full Price




Reduced Lunch

No Charge

No Charge

No Charge

Free Lunch

No Charge

No Charge

No Charge

         No charge for Middle School grade students. (Grades 5 – 8)


Charges for Afterschool attendance will be billed by the ASP Office at CNSU. Payment is due ten days after the invoice is sent. If you are unable to make a timely payment, please contact Karen Thompson, Afterschool Assistant, at 626-6100, ext 212, to make alternate arrangements. Checks, money orders or cash will be accepted; payment plans are available if needed. PLEASE DO NOT GIVE CASH TO AFTERSCHOOL STAFF AT YOUR SITE; Karen Thompson is available at the CNSU office, Mon – Fri, 8:30 – 3:00 p.m. to accept payment.


If you are unable to afford program fees for your child(ren) to attend afterschool, please ask your school principal for a scholarship application. The principal will make a recommendation regarding scholarship need to the Afterschool Program Director.




Parent/Guardian Signature:  _________________________________________   Date:  ________________