Hughes After-School

An after-school program for all students!

Registration Form

Student’s Name (print): _______________________________ Nick Name: __________

Middle School Team: ___________________________________ Grade: ___________

Parent/Guardian Name: ___________________________________Email____________

Home Address: __________________________________________________________

Home Phone: ______________________ Cell Phone: ___________________________

Mother’s Work Phone: ________________ Father’s Work Phone: _________________

Emergency Information (If mother or father can not be reached)

Adult Contact: ______________________ Relationship: __________________________

Primary Phone Number: ____________________ Back-up number ________________

Allergies: _______________________________________________________________

Special instructions: _______________________________________________________

Medications: ______________________Limitations:_____________________________

After-school activities will include a blend of homework assistance, tutoring, school clubs, community service, arts and crafts, leadership, cooking, recreation, and other activities. Students who participate can remain after school until late bus pick up or 6:00 p.m. for parent pick up. Students will be provided a snack during the program hours.

Please indicate when your child will attend the After-School Program:

Monday 2:20 – 3:30 (late bus) 2:20 – 6:00 (parent pickup)

Tuesday 2:20 – 6:00 (parent pick up)

Wednesday 2:20 – 4:00 (late bus) 2:20 – 6:00 (parent pickup)

Thursday 2:20 – 4:00 (late bus) 2:20 – 6:00 (parent pickup)

Friday 2:20 – 6:00 (parent pick up)

My child is also being registered with the Reston Teen Center program.

Continued participation in the After-School program is contingent on the student’s attention to school behavioral guidelines. Student may be denied participation and parents will be asked to pick up their child if the guidelines are not followed.

I, (student’s name) ____________________________ understand and agree to follow FCPS Student Rights and Responsibilities, the Hughes School rules, and bus rules while participating in the program. Sign: ________________________

I hereby grant permission for my child to participate in the After-School program during the 2007-2008 school year. I understand that participation is voluntary and that some of the planned physical activities may expose my child to some potential injury. I agree that, to my knowledge, my child is physically and medically able to participate in these activities. If any injuries do occur, I understand that school personnel will respond in the same manner that occurs during regular school hours. I understand that a late fee will be charged for late pick up.

Parent/ Guardian Signature: __________________________________ Date: _______