School/Homework Club

313 Cedar Street   Ashland, MA 01721    508-395-8345

(circle) T W  TH    2-4:30    2:30-4:30    3-4:30    3:30-4:30                           

Child’s Name ___________________________________________   Nickname _____________

Child’s age ________      Birthdate ______________  Sex _______

Home Address ________________________________________  Phone __________________

Town ________________________________________________  Zip Code _______________

Parent/Guardian Information:

Parent/Guardian’s Name __________________ Parent/Guardian’s Name ____________________

Relationship to child _____________________ Relationship to child _______________________

Home Address _________________________ Home Address ___________________________

Home Phone ___________________________ Home Phone _____________________________

Cell Phone _____________________________ Cell Phone ______________________________

Occupation ____________________________ Occupation _____________________________

Business Address _______________________ Business Address _________________________

Business Phone _________________________ Business Phone ___________________________

Email Address _________________________  Email Address ___________________________

Names and ages of siblings and household members _____________________________________

___________________________________________________________________________

People who are authorized to pick up your child:

Name ______________________________________ Phone ___________________________

Name ______________________________________ Phone ___________________________

ALLERGIES __________________________________ Child’s Physician ___________________

                                                                    Physician’s Phone ___________________

Additional Information special accommodation requests, identified special needs, developmental support needed, etc)

____________________________________________________________________________

____________________________________________________________________________

School/Homework Club

WHAT I NEED (label everything)

• Backpack
• Snack and a drink
• Extra clothing
• Clothing for weather (hat, raincoat, boots, mittens, snow pants, etc)
• Hand sanitizer (labelled with name)
• Water bottle (labelled with name)
• Family chosen participation schedule (unstructured farm learning versus school assignments)

Additional Items (not required)

• Insect repellant wipes for children to use independently
• Food scraps (banana peels, watermelon rinds, apple cores, peels, ANY fruit or vegetable no longer good for human consumption NO AVOCADOS (poisonous)

Please cut along line and return with your child on the first day of class

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My child/ren has permission to participate in this program and I have completed a registration form and application with all required information. I authorize Courtney Arseneault and the staff at Adventures in Learning to support my child and assist with school assignments.  I understand this program is completely outdoors.  If online, my child will be responsible for their device and follow public school policies for assignments.

Child’s name: _______________________________________________________________

• Has permission to participate in all farm based activities (interacting with animals, completing farm chores, feeding animals, exploring woodland and garden areas, and all farm based activities. Cannot participate in (ie egg collecting)_______________________________________________________

Medications: ___________________________________________ I give consent to administer in the event of an emergency      *EEC medication form must also be completed

I give Courtney Arseneault and AIL staff permission to administer first aid and have my child transported in a health emergency.

Insurance information: ___________________________________________________________________

Emergency info at a glance:

Emergency Contact and number ___________________________________________________________

I have read all related information for Home/Schoolwork Club and agree to policies and my tuition payment schedule

Current School:________________________________________________________________

School Address:_______________________________ School Phone Number:_________________________

I certify that documentation of physical examination and immunizations in accordance with public school health requirements and lead poisoning screening in accordance with public health requirements are on file at my child’s school. Parent/Guardian initials: _______________________________________________ ________

Parent/Guardian’s name, signature, and date ___________________________________________

Daily Schedule  Child’s Name ______________________________ Week of _________________

Family chosen activities

• All farm based learning activities to support overall learning
• ½ scheduled time unstructured farm learning ½ school assignments

School Assignments:

Language Arts:

Math:

Science:

Social Studies:

Projects/Papers/Special Assignments: