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After School Program Registration Form

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The Afterschool Program Registration Packet

A safe & fun place where children with special needs can grow, develop, and learn through recreation.

A partnership of the Rochester Parks & Recreation Department and Bear Creek Services Inc.

This program offers a safe & stimulating recreational environment after school hours for children with a variety of special needs. Participants benefit from activities involving fine & gross motor skills, individual & group activities, music therapy, dramatic play, and sensory stimulation with an emphasis on socialization and communication. An afterschool snack, homework help, and transportation from a Rochester Public/Private school or residence to Bear Creek Services are also provided.

DATES: Tuesday, September 6, 2011 – Friday, June 7, 2012. Closed on holidays and Rochester School District days.

WHO: Youth ages 4-18 year of age with a Developmental Disability. Persons 19 years of age and with a Developmental Disability are eligible if they are currently in school.

TIME: 2:30-6:00 p.m.

WHERE: Bear Creek Services, 3018 Hwy 52 N. Rochester, MN 55901.

COST: $3400.00

Program Services

* Experienced and well-trained staff will supervise and facilitate all activities.

* Music Therapy.

* Transportation provided from schools within the Rochester School District.

* PECs and Visual Schedules used.

* Stimulating activities offered daily.

* Accessible playground!

* Comfortable and open activity area and classrooms.

* Individual & group time activities.

* Homework, reading, & snack time daily.

* Open from 12:30-6:00 p.m. on early release days (based on the Rochester Public School District calendar).

Program Overview

This therapeutic program offers children with special needs an opportunity to develop friendships, as well as the use of social, physical, and cognitive skills through an assortment of activities including arts, crafts, games, social play, and large motor activities. There will be a daily snack, reading & homework time.

Cost of the program includes transportation to Bear Creek Services (BCS), from a designated site within the Rochester Area. Transportation home will be up to families. Pick up is scheduled for 6:00 p.m.

Supervision & assistance is based on a 1:4 (staff to child) ratio and will be provided by experienced and well-trained staff.

Days / Times Offered

The program will be open Mondays-Fridays, 2:30 – 6:00 pm, school days only.

Facility

The program will be hosted in the center space at Bear Creek Services, located at 3018 Hwy 52 N. Rochester, MN 55901. The BCS site allows for multiple spaces for a variety of activities.

Program Cost/Financials

Cost of the program is $3400.00 for the school year (September 2011-June 2012). Checks can be made payable to the Parks & Recreation Department. If another agency/party is paying the tuition, you can include that information on the form below and we will bill them for you. All payment must be received BEFORE participation is allowed.

Absences due to illness/Appointments/Etc.

If your child is sick or will not be attending the program for any reason notification MUST be made BY 1:00 p.m. the day of the program and can be made to Karen Meyer at (507) 328-2539 or to kmeyer@rochestermn.gov

Late Pick Ups

There will be a $7.00 late fee per child charged for late pick up AFTER 6:00 p.m. The fee will increase an additional $7.00 every 15 minutes and must be paid before your child can attend the next program day. Participation will resume once the balance is paid to the Parks & Recreation Department at 201 4th Street SE #150, Rochester, MN 55904. When running late, PLEASE CALL THE PROGRAM STAFF AT (507) 226-2787.

Registration Information & Process

Registration will be accepted Tuesday, July 5 until space is filled OR by Friday, July 15, 2011. Space is limited, registration is first come/first serve; space may fill BEFORE registration ends.

Please complete and return the following forms:

Registration Form

Release/Waiver Form

Payment (Initial payment only)

Program Cost & Payment

Full cost of the program for the year (Sept. 2011-June 2012) is $3,400.00 and payments are scheduled as such:

* Initial payment of $1,133.00 due with registration materials between July 5 & 15, 2011.

* 2nd Payment of $1,133.00 due November 10, 2011.

* 3rd and final payment of $1,134.00 due March 10, 2012.

Send Payment & Forms to:

The Parks & Recreation Department
Adaptive Recreation Division
201 4th Street SE #150
Rochester, MN 55904

Questions? Call Karen Meyer, Director of Adaptive Recreation at (507) 328-2539 or email kmeyer@rochestermn.gov

The Afterschool Program Registration Form

Please complete and return along with payment to the Parks & Recreation Department, 201 4th Street SE #150, Rochester, MN 55904 by Friday, July 15.

Child’s Name:

Parent’s Name:

*Home Phone:

*Emergency Phone:

*Cell Phone:

Home Address:

DOB:

Age:

Diagnosis:

1. Are you requesting transportation from your child’s school/other location (Rochester only) to Bear Creek Services?

Yes    No

If no, who will be transporting him/her?

If yes, location where will your child need to be picked up:

Name & Address of location:

What door/side of building:

List the person(s) responsible to meet us with your child:

Does your child use a booster and/or safety car seat while transporting? Yes No

Please complete and return the attached forms along with this form and payment to the address above.

Afterschool Program Waiver / Release

RELEASE

The City of Rochester and Bear Creek Services Inc., their officers and employees hereby agree to allow to participate in the Afterschool Program collaborative with Bear Creek Services, Inc. and the Parks & Recreation Department from September 2011-June 2012 and agree to provide transportation in Bear Creek Services/Parks & Recreation vehicles driven by said agencies’ staff from a specified school or other specified location within Rochester to the program site of Bear Creek Services, Inc. as well as any activities associated with the Afterschool Program during program hours.

In order to participate in this activity, I agree on behalf of the participant named above to hold the City of Rochester and Bear Creek Services, Inc. their employees and agents harmless and waive any right to make claims or lawsuits against the City and/or Bear Creek Services Inc. or anyone working on behalf of the City and/or Bear Creek Services Inc. or anyone working for Bear Creek Services, Inc. for any injuries or damages related to the alleged negligence of the City and/or Bear Creek Services, Inc. This waiver does not apply to any injuries or damages that are the result of any willful, wanton or intentional misconduct. Participation in this activity is voluntary and I understand the effect of this waiver on my legal rights and those of the participant named above.

Signed:

Dated:

AND

TRANSPORTATION

I give permission for my child to be transported from said location by Bear Creek Services Inc. & Parks & Recreation Department staff to the Afterschool Program site at Bear Creek Services, Inc.

Yes    No

My child will NOT be taking transportation by Bear Creek Services Inc., but will be transported to the Afterschool Program site at Bear Creek Services by:

Mother

Father

Other family member

Staff

Volunteer Driver

AND

PHOTOGRAPHS

My permission is given / is NOT given for my child’s picture to be taken and image used in the media and/or for purposes associated with the Afterschool Program.

My permission is given My permission is NOT given

MEDICATION

Sunscreen is considered “medication” and we must have written permission to administer it AND any other medications to your child while they are with us at the program.

I give permission for Park & Recreation Staff to administer sunscreen to my child.

I do NOT give permission for Park & Recreation Staff to administer sunscreen to my child.

will need to have the following medications dispensed to him/her by the Park & Recreation Department staff during the program:

Name of Medication Amount to be Given Time to be Given

Please note: if there are any changes or adjustments to your child’s medication or the way it is administered, you must make written updates on a new form.

Signed:

Dated:

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What the After School Program Registration Form Is

An After School Program Registration Form is a standardized document used to enroll a child in an extracurricular program, record guardian and emergency contact information, capture medical and allergy details, and document permissions and waivers. The form creates a single, auditable record of authorization for pickup, field trips, and routine medical care while a child is in program custody. When completed electronically, the form can include an audit trail and eSignature, and may interact with privacy rules such as FERPA for student records and HIPAA when health information is collected.

Why a Clear Registration Form Matters

A professional form reduces administrative delays, documents consent and emergency instructions, and limits liability by providing written authorizations and contact details. Accurate forms streamline pickup authorization, medical responses, and program attendance tracking while preserving an auditable record suitable for eSignature workflows under ESIGN and UETA.

Why a Clear Registration Form Matters

Who Completes and Relies on This Form

The form is completed by parents or legal guardians and used by program staff to manage attendance and safety.

  • Parents and guardians who enroll children and provide consent and medical details for care.
  • Program coordinators and site staff who use contact, allergy, and authorization information daily.
  • District or vendor administrators who verify eligibility, process payments, and maintain compliance records.

Completed forms are also retained by school or vendor administrators for compliance, reporting, and emergency response purposes.

Essential Sections of a Professional Registration Form

A complete registration form groups related information into discrete sections so staff can quickly find authorization, medical, and scheduling details without ambiguity or missing data.

Student Identity

Full legal name, preferred name, date of birth, grade, and school enrollment to match district records and emergency systems.

Guardian Contacts

Primary and secondary guardian names, phone numbers, relationship, email, and authorized pickup designees for immediate contact and verification.

Emergency Contacts

Two or more emergency contacts with phone numbers and relationship if guardians are unavailable, including out-of-area contact if applicable.

Medical Details

Allergies, chronic conditions, medications, physician contact, and required documentation or action plans for on-site care or medication administration.

Permissions & Consents

Field trip permission, photo/video release, transportation authorization, and specific activity waivers with explicit yes/no selections.

Signature Block

Printed name, signature (electronic or handwritten), date, and acknowledgement of program rules, participation risks, and emergency treatment authorization.

Security and Compliance Considerations

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
Access Controls: Role-based access and audit trails
HIPAA Readiness: BAA available when health data collected
FERPA Awareness: Limit disclosure of education records to authorized users
Audit Trail: Timestamps, IP, and action logs recorded
Certifications: SOC 2 Type II, ISO 27001, PCI DSS

Step-by-Step: Filling and Submitting the Form

Follow these sequential steps to gather required information, complete the form accurately, and ensure the form is properly authorized and retained.

  • 01
    Gather Documents: Collect ID, insurance, and medical action plans before starting.
  • 02
    Complete Fields: Enter all required fields and double-check contact numbers.
  • 03
    Provide Consent: Answer permissions questions explicitly; do not leave blanks.
  • 04
    Sign and Submit: Sign electronically or by hand and forward to program staff.

Configuring an Online Registration Workflow

Set up the digital workflow to validate fields, route approvals, and retain records securely for staff access and reporting.

Field Configuration
Signing Order Parent/guardian signs first; coordinator acknowledges second
Authentication Use email with optional SMS code verification for signers
Conditional Fields Show medical fields only if 'Has medical needs' selected
Notifications Email confirmations to guardians and program administrators

Technical Formats and Integration Notes

Choose platforms that accept common formats and integrate with your student information systems to avoid manual entry.

  • Formats Supported: PDF, Word DOCX, and HTML
  • Integrations: Salesforce, NetSuite, Microsoft 365, Google Workspace
  • Accessibility: WCAG 2.0 Level AA support recommended

Routing: Where Completed Forms Go Next

After completion the form should be routed to the program coordinator, stored in the student record, and copies provided to guardians and emergency contacts as appropriate.

  • Program Coordinator: Primary recipient for enrollment and daily operations
  • Student Information System: Record enrollment and scheduling details centrally
  • Guardian Copy: Provide a signed copy to the parent or guardian
  • Emergency Contacts: Accessible copy for staff responding to incidents

Typical Deadlines and Update Requirements

Deadlines vary by program. Establish clear enrollment windows, renewal intervals, and timelines for updating critical information to keep records current and compliant.

Program Enrollment Window:

Submit completed forms before the program start date

Annual Review:

Update contact and medical information yearly

Immediate Updates:

Report changes to emergency contacts within 48 hours

Medication Authorization Renewal:

Renew physician-signed medication orders annually

Record Access Requests:

Respond to guardian requests per district timelines

Common Errors to Avoid

  • Leaving emergency contact fields incomplete or listing only one unreachable number delays response during incidents.
  • Providing inconsistent names or DOBs that do not match school records causes verification and enrollment delays.
  • Failing to sign or date the form—unsigned forms may be treated as incomplete and deny participation.
  • Omitting required medical authorization or action plans for chronic conditions can prevent staff from administering medication.

Consequences of Incomplete or Incorrect Forms

Denied Participation: Child may be excluded until a complete form is received
Medical Risk: Insufficient information can impede timely treatment
Liability Exposure: Program may face claims if consent or authorization missing
Data Privacy Breach: Improper handling of records risks FERPA/HIPAA noncompliance
Administrative Burden: Incomplete forms increase staff follow-up and processing time
Funding Impact: Noncompliance with reporting may affect grants or reimbursements

Comparing eSignature Providers for Registration Workflows

Common selection criteria include per-user pricing, trial availability, support for bulk send, audit trails, and HIPAA support where health data is collected.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes (Business Premium) Varies by plan Varies by plan Varies by plan Varies by plan
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA available) Varies by plan Varies by plan Varies by plan Varies by plan

Frequently Asked Questions and Troubleshooting

Answers to common questions about completing, signing, and managing After School Program Registration Forms in digital and paper workflows.


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