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2024 Enrollment Application
Project Rise Summer Program 2024
Please complete an application for each child to be considered for enrollment.
Step
1
of
8
12%
Student Information
Today's Date
(Required)
MM slash DD slash YYYY
Has your child enrolled in our program before?
(Required)
Yes
No
If yes, when?
Child's Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
Cell Phone
(Required)
Social Security Number
(Required)
Child's MSIS Number
Birth Certificate
Max. file size: 512 MB.
Please upload a copy of the child’s birth certificate.
Race
Sex
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Age
(Required)
School
(Required)
Grade
(Required)
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
Clothing Size
(Required)
Youth Small
Youth Medium
Youth Large
Youth Extra Large
Adult Small
Adult Medium
Adult Large
Adult Extra Large
Parent/Guardian Information
Parent/Guardian Name
(Required)
First
Last
Email
(Required)
Social Security Number
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
ID of Parent/Guardian
Max. file size: 512 MB.
Please upload a copy of the parent/guardian’s ID.
Race
Sex
(Required)
Marital Status
(Required)
Head of Household
(Required)
Education Level Completed
(Required)
Do you have insurance?
(Required)
Yes
No
Insurance Provider
Policy Number
List all persons living in the household.
(Required)
Include Name, Relationship to Child, Age, and Enrollment Status.
Are you employed?
(Required)
Yes
No
If yes, who is your employer?
Employer's Phone Number
Employer's Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Income Information
How often do you currently receive income?
(Required)
Weekly
Twice Monthly
Monthly
Annually
Amount Received
(Required)
Name of Employer for Any Other Individual Living in the Home
Please include individual’s name, employer’s name, employer’s address, employer’s phone number.
List the Type and Amount for Any Other Sources of Income
Please include Child Support, TANF, Social Security, Unemployment, Food Stamps, Utility Check/HUD, Disability, Pension/Retirement.
Proof of Income
Max. file size: 512 MB.
Please upload proof of income.
Child's Name
First
Last
Emergency Contact
Please list individuals to be notified in an emergency situation other than the parent/guardian. Include Name, Relationship to Child, and Phone Number. The above persons may also pick up the child from Operation Shoestring. I understand that the persons listed must present proper identification if requested.
Consent
Child's Name
First
Last
Parent/Guardian's Name
First
Last
Photography/Videography Consent
(Required)
I agree to the Photography/Videography policy.
I, the parent/legal guardian of the child listed above, give my consent to the photographing, videoing, or any other means of recording the child listed above by Operation Shoestring staff, any of its partners, or designated third-party affiliates as deemed appropriate.
Transportation Consent
(Required)
I agree to this Transportation policy.
I, the parent/legal guardian of the child listed above, give my permission to be transported on the Operation Shoestring van and/or Jackson Public Schools transportation to and from Galloway Elementary. My child has permission to be transported to and from approved field trips on transportation arranged by Operation Shoestring.
A separate permission slip is required for each field trip. Should there be an occasion for children to walk to and/or from Galloway, Operation Shoestring and/or a satellite location: All children will walk under the direct supervision of Operation Shoestring staff. At each street crossing a staff person will verify that oncoming traffic is aware of the intended crossing and have come to a complete stop. Before signaling for children to cross, staff will post a crossing guard holding a stop sign in front of the stopped traffic. One staff person will be first to cross and another will be last to cross at the end of the group.
Educational Records Release
I agree to this Educational Records Release policy.
I, the parent/legal guardian of the child listed above, grant permission for the release of school records (student achievement records, test scores, progress and attendance reports, MCT2 scores, term grades, and other relevant student assessment data) to Operation Shoestring, Inc. of 1711 Bailey Avenue, Jackson, MS 39203.
Project Rise After-School Program will need to periodically review and utilize educational information and records developed and maintained by the Jackson Public Schools in order to accurately develop and plan interventions to help me help my child manage and balance his/her needs for success in school. It is my understanding that all personal records and information pertaining to my child and family will remain strictly confidential.
This release also gives Project Rise After-School Program permission to confer with my child’s classroom teacher to review and discuss educational, pre/post assessment, attendance and discipline records. I understand that all such records pertaining to my child will remain strictly confidential.
Emergency Medical Treatment Consent
(Required)
I agree to this Emergency Medical Treatment policy.
I, the parent/legal guardian of the child listed above, give my permission, in case of an emergency, to the staff of Operation Shoestring’s Project Rise After-School to obtain necessary medical care for my child. In the event of a medical emergency, I understand that the staff will attempt to contact me as soon as possible.
Date
MM slash DD slash YYYY
Critical Medical Information
Please list any medical or emotional conditions that your child has that the center staff should be aware of.
Physician's Name
(Required)
Physician's Phone Number
(Required)
Preferred Hospital
Insurance Provider
Policy Number
Parent Handbook Acknowledgement
I have received a copy and read the Parent Handbook for Operation Shoestring Project Rise
(Required)
Yes
I understand and agree to Operation Shoestring Project Rise Parent Handbook policies and procedures as it is stated.
(Required)
Yes
I understand Operation Shoestring Project Rise Photography/Video consent.
(Required)
Yes
I agree and give consent to allow Operation Shoestring to contact any persons listed for Pick-up, Emergency Notification and give Emergency Medical Treatment.
(Required)
Yes
I understand and agree to Operation Shoestring Car Rider Policy, permission for Field Trips and Transportation Policy.
(Required)
Yes
Parent Handbook Acknowledgement
(Required)
By checking this box, I attest that I have received a copy of Operation Shoestring’s Parent Handbook and a summary of child care licensing regulations.
Transportation Information
Dear Parents, Our after-school students are transported to Operation Shoestring from Galloway Elementary School as both a courtesy and expense of the Jackson Public School District. It is imperative that we respect their generosity and the terms of our transportation agreement. Therefore, we must comply with the same rules and regulations that Jackson Public Schools enforce for all of its bus riders. This means the following: – Students who are suspended from the bus will be suspended from our program for the same number of days. – Any student that causes habitual behavior on the bus will be suspended from the after-school program. The student will then be required to get home by whatever means were established with the school system upon their enrollment in Galloway Elementary School. – If a student’s behavior becomes disrespectful, disruptive, or dangerous for himself/herself, the driver, Operation Shoestring staff, or other students, he/she will be suspended from the after-school program. We thank you in advance for your cooperation regarding this matter and look forward to peaceful, pleasant bus rides for the remainder of the school year. Please check the box below to indicate that you understand and support our efforts to maintain our transportation relationship with the Jackson Public School District. Sincerely, Lakesha Partee, Program Coordinator Operation Shoestring, Inc.
Child's Name
First
Last
Child's Grade Level
Consent
I agree to this Transportation policy.
I, the parent/legal guardian of the child listed above, have read the above transportation notice. We both understand and support efforts to provide safe and orderly transportation for my child(ren) to and from Operation Shoestring.”
Date
MM slash DD slash YYYY
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