Grades 6 to 8 After School Program Permission Form

Details: Written by: JMMY Center; Category: Forms and Documents

Form for signing up your student to the grades 6-8 After School Program.

The J.M.M.Y. Center in the Town of Georgia is adding a new After School Program for Grades 6,7, and 8 every Thursday that school is in session beginning September 11th during the GEMS 2025/26 school calendar year. The program includes education on youth risk prevention and healthy choices; followed by a fun activity such as ping pong, billiards, volleyball, board games, woodworking or arts and crafts; and closes with a nutritional snack or meal. Along with fun activities, this program would like to introduce and encourage participation in local community service. This will include community outreach, occasional field trips, and visits from presenters and other activity leaders. The program plans to play to the strengths in each youth and try to guide them to be the best they can be.

The program is under the direction of the board and presented by “Chip” Chiappinelli, MD, pediatrician, and Mary Chiappinelli, RN, former GEMS school nurse. Parents can sign up their youth using the form below.

We can arrange for students to ride the school bus to the J.M.M.Y. Center. Parents must pick up their own child promptly at 5pm. Volunteers are scheduled until that time only. If you plan to carpool with another family, the J.M.M.Y. Center must have written permission from the parent who is allowing their child to ride home with someone else. Parents must come inside to pick up their child.

If you’d like more information, please contact us at afterschool@jmmyvt.org

Sincerely,
The J.M.M.Y. Center Board

JMMY Center After-School Permission Form

This form is a summary of the JMMY Center conduct policy. A copy of the full conduct policy and bylaws are available upon request.

1. Our main concern is the safety of all participants

Each participant has the right to have fun and be protected from any harassment. The environment is completely smoke, drug and alcohol free. Everyone has the right to participate in the after-school activities in the JMMY Center and to abide by the rules of the center. The JMMY Center has an open policy, all children are encouraged to participate in events, but it is entirely voluntary. Children in the after-school program must have a signed permission form, bus drop-off permission (turned into the GEMS office) and have a designated person who will pick them up. Children will not be released into the custody of anyone without the expressed permission of the parent/guardian.

2. We will handle misconduct appropriately

Any misconduct committed as outlined in the disciplinary policy will be handled with the smallest audience possible. We reserve the right to withhold access for any individuals who consistently refuse to abide by the conduct policy or commit serious infractions.

3. All volunteers are there to help your child

All volunteers have been fingerprinted and federally background checked. They are here to assist your child with any needs they may have. Each volunteer is a mandated reporter and is required to report any form of possible abuse.

4. We are not sponsored by the school

We are an independent organization that works closely with Georgia Plain Baptist Church. Our goal is not to solicit church involvement, but to provide a safe, nurturing space for the children and youth of Georgia. All our funding comes from donations, fundraisers, and grants.

By filling out and submitting this form, you are indicating that you agree with the stated afore mentioned. Furthermore, all the following information will remain strictly confidential and will not be shared with any other party.

Child's name *

Name of the child who will be attending this activity. If more than one child will be attending, please fill out a separate form for each child

Grade *

Parent's name *

Name of the parent or guardian authorizing the child the participate in this activity

Street address *

Town *

Home phone # *

Parent's cell phone # *

Parent's email address *

Allergies or medical conditions *

Students will have a snack once they arrive at the JMMY Center. Please let us know about any allergies or medical concerns that we should consider in regards to your child

Emergency Contact (if unable to reach parent)

Contact name *

Contact phone # *

Agreement *

I agree to the above-listed guidelines and certify that all the information I entered above is true and accurate

Today's date

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