MLK Afterschool Program K-8
2023-2024 Registration Form

Parents/Guardians & Students of James Whitcomb Riley School 43: The MLK Center is the after-school program provider for your child's school. The goal is to have every student reading at grade level and provide fun activities.

Please fill out a registration form for EACH child you are wanting to attend programming. You will be contacted by a staff member within 3 days to discuss enrollment or a waiting list.

When:The first day of programming is Monday, August 7, 2023. The program starts immediately after school dismissal Monday through Friday. It's important your child attend every day. We understand middle school students may have sports or other extra-curricular activities. Teachers will escort students to the cafeteria where MLK Center staff will check them in & transport them to MLK Center.
I acknowledge that I have read and understand the above statement.
Program:The program is focused on reading and literacy, so that your child is reading at or above grade level. We will provide one-on-one instruction where needed to support your child. The program also provides recreation, snacks and youth development. We will work closely with you, teachers and staff to support what your child is learning in the classroom.
I acknowledge that I have read and understand the above statement.
Cost:The cost is $60 per week. Scholarships are available. If you do need assistance with the weekly fee, please contact Lacrisha Hollins at Lacrisha@MLKCenterIndy.org to discuss arrangements. Payments can be made at the front desk and a receipt will be given.
I acknowledge that I have read and understand the above statement.
Pickup/Dismissal:All children must be picked up by 7:00 p.m. or a fee may be charged. You or someone on the approved pickup list must come inside and sign your child out. Please use designated parking spots and do not park right in front of the door. Call 317-923-4581 as soon as you can in the event of an emergency.
For Middle Schoolers: If you want your middle school child to be able to walk home, you must speak to the middle school coordinator in person.
I acknowledge that I have read and understand the above statement.
Parent Support:You are part of our MLK Center Community! We have a variety of activities, programs and support services for families including parent support groups, rental/housing assistance, financial coaching, employment support and free mental health counseling on-site.
I acknowledge that I have read and understand the above statement.
Contact Information:Front Desk: Call 317-923-4581
Youth Program Director: Lacrisha Hollins, Lacrisha@MLKCenterIndy.org
‍Elementary School After School Coordinator: Azure Riley, Azure@MLKCenterIndy.org
‍Middle School After School Coordinator: Adam Thomas, Adam@MLKCenterIndy.org
YOUTH INFORMATIONChild's First NameChild's Last NameLast 4 Digits of SS#
Date of Birth
School Enrolled:James Whitcomb Riley School #43
Gender
FemaleMaleNon-binaryRace
African American or Black
Caucasian or White
American Indian or Alaskan Native
Asian
Hawaiian or Pacific Islander
African
Two or More Races
OtherEthnicity
HispanicNon-HispanicGradeSpecial Medical Health Needs?Allergies/Dietary RestrictionsMedications To Be TakenParent/Guardian Information
Primary Parent First NamePrimary Parent Last NameRelationship to ChildEmail AddressStreet AddressZip CodeCell Phone NumberWork Phone NumberHome Phone NumberDate of Birth
Gender
FemaleMaleNon-binaryRace
African American or Black
Caucasian or White
American Indian or Alaskan Native
Asian
Hawaiian or Pacific Islander
African
Two or More Races
OtherEthnicity
HispanicNon-HispanicLast 4 Digits of SS#
Marital Status
DivorcedDomestic Partner
Married
Single (Never Married)
Separated
Widowed
Highest Level Of Education Completed
Less than high school
High School/GED
Some College
Two-Year Degree
Technical Degree/Certification
Four-Year Degree
Masters Level Degree
Doctorate Degree
Total Estimated Household IncomeHow many total people are living in your household?
Household Makeup:
Single Parent/Head of Household
Two Parent Household
Grandparent(s)
Other
Employment Status
Employed Full-Time (35 hours or more each week)
Employed Part-Time (Less than 35 hours each week)
Unemployed (Seeking Employment)
Not in the workforce (homemaker, disabled, retired)
OtherSecondary Parent First NameSecondary Parent Last NameRelationship to ChildEmail AddressStreet Address (if different)Zip CodeCell Phone NumberWork Phone NumberHome Phone NumberEmergency Contacts
Add up to three local people who can be reached during program hours if a parent or guardian is not available (required). For your child’s safety, he/she will be released ONLY to those listed on this page. All authorized persons must be 18 years of age or older and have a photo ID. Changes to this list must be made in writing and may only be done by the parent or legal guardian whose signature appears on this registration form.
EC#1 First NameEC#1 Last NameEC#1 Relationship to ChildEC#1 Cell Phone NumberEC#2 First NameEC#2 Last NameEC#2 Relationship to ChildEC#2 Cell Phone NumberEC#3 First NameEC#3 Last NameEC#3 Relationship to ChildEC#3 Cell Phone NumberAuthorization, Acknowledgement and Release
Media Release: I give permission for my child(ren)'s image to be included in any promotional/media resources related to MLK Center and/or the school, including printed brochures, flyers, MLK Center website, social media pages or photos included with press releases to local media. MLK Center will not identify children by name.
AgreeDisagreeData Sharing: I give my permission for MLK Center to collaborate with my child's school system, in securing copies of grades, assessments, attendance, discipline referral, suspension information, shot records and school counselor's reports, IEP and other reports to help MLK Center staff support my child's educational process. I give permission to share data with IPS and United Way of Central Indiana for program and outcome data collection purposes.
AgreeDisagreeClient Confidentiality: MLK Center values the privacy of all individuals and families we serve. All information given to MLK Center will be held in strict confidence and released based on these permissions unless we are authorized by the individual or minor's parent or guardian, for disclosure or a court order is issued requiring the release of specific information.
AgreeDisagreeGrievance Policy: You have the right to receive services in a professional and respectful manner. Parents who feel that they have a complaint or grievance can follow the following procedure:
1. Report the incident/complaint to the Program Director for review. The Program Director is to provide a response within 2 business days.
2. If parents still believe that the situation was not resolved, request a review by the Executive Director. The Executive Director will speak to all parties involved and provide a written response within 7 business days of completing a review of all the information.
3. If parents still believe that the situation was not resolved, request a review by the MLK Center Board President. The Board President will review all information and provide a written response within 14 business days of completing a review.
AgreeDisagreeTransportation: I give permission for my child(ren) to use bus/van transportation provided by MLK Center for field trips or other program related activities. I understand that only licensed and qualified personnel will operate any vehicle to and from the site. I agree to release the Martin Luther King Community Center, its officers and directors and staff from any and all claims of damages, demands or liabilities, which may arise as a result of my child's participation in MLK Center's transportation service.
AgreeDisagreeBehavior Policy: I understand that MLK Center's priority is to provide a safe and enriching experience for all children. For MLK Center to provide a positive, nurturing environment, we will not continue to serve children who repeatedly display disruptive behavior, such as hitting, kicking, spitting, hostile verbal behavior and other behaviors which will hurt another child. In response to these behaviors, the MLK Center will not use threats or bribes, physical punishment even if requested by the parent, deprive your child of food or other basic needs, humiliation or isolation. In response to misbehavior, we will: respect your child, establish clear rules, be consistent in enforcing rules, use positive language to explain desired behavior, speak calmly while bending down to your child's eye level, give clear choices, redirect your child to a new activity and move your child to a time-out chair for no longer that one minute per year of your child's age if necessary. We will work with both the child and family to address and modify any behavior concerns; however, if a child continues to display inappropriate behavior, then he/she may be removed from the program.
AgreeDisagreeEmergency Treatment: I hereby give permission to the MLK Center staff to call emergency personnel for me or my child(ren), in the event I am not able to communicate or cannot be reached in an emergency. I will be fully responsible for any costs of such treatment, even if not covered by insurance.
AgreeDisagreeElectronic Signature: I affirm that I have read the rules and program description and understand my rights and responsibilities and the expectations of my child(ren). I certify that I am the parent or legal guardian of this child and I have the legal authority to make the representations and grant the authorizations contained herein.
Today's Date
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MLK Afterschool Program K-82023-2024 Registration Form

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MLK Afterschool Program K-8
2023-2024 Registration Form