Before & Aftercare Enrollment

2026-27 Enrollment Form

WATERVLIET CIVIC CENTER BEFORE & AFTER SCHOOL PROGRAM

Child & Guardian Information

Child Information

Childs Name

Childs Cell #

Street Address

Date of Birth

Address

City

Zip Code

Grade in Sept.

Gender

Guardian One Information

Parent/Guardian's Name

Cell #

Home #

Parent/Guardian's Work #

Street Address

Address

City

Zip Code

Guardian Two Information

Parent/Guardian's Name

Cell #

Home # (If different)

Parent/Guardian's Work #

Street Address If Different

Address

City

Zip Code

Financial assistance is available through DSS for qualifying families. Our team is happy to help guide you through the process.

Emergency Contacts

IN THE CASE OF AN EMERGENCY, LIST PEOPLE TO BE CONTACTED IF NEITHER PARENT CAN BE REACHED. * MUST BE IN ADDITION TO PARENTS OR GUARDIAN. YOUR CHILD WILL ONLY BE RELEASED TO THE INDIVIDUALS ON THIS FORM. ALL OF THE INDIVIDUALS LISTED MUST BE AT LEAST 16 YEARS OF AGE AND HAVE PHOTO IDENTIFICATION.

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Emergency Contact 1

Name

Phone #

Street Address

Address

City

Zip Code

Employer

Work #

Relationship to Child

Emergency Contact 2

Name

Phone #

Street Address

Address

City

Zip Code

Employer

Work #

Relationship to Child

Medical Information

Please list name of family doctor, hospital of choice in case of emergency, allergies, disabilities, medical conditions & health insurance information.

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Family Doctor

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Address

Phone #

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City

State

Zip

AllergiesMedications Currently TakenMedical Concerns

My Child does have a diagnosed severe developmental disability*

YES

*** If Yes, a treatment/behavioral plan must be established

A Watervliet Civic Center Staff Member has permission to apply sunscreen to my child*

YES

Hospital of Choice

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Health Insurance Company

Policy #

EACH CHILD WHO ATTENDS THE SUMMER RECREATION PROGRAM MUST HAVEAN UPDATED IMMUNIZATION RECORDS. NO CHILD WILL BE ALLOWED TOATTEND THE PROGRAM WITHOUT AN UPDATED IMMUNIZATION RECORD.

Enrollment

PLEASE CHECK WHICH PROGRAM YOU WISH TO ENROLL YOUR CHILD IN

Before School

After School

Both

2026-2027 Before & After School Program Program Closure Form

If the Watervliet City School District closes at regular dismissal time, but they cancel their after-school activities the Watervliet Civic Center will not operate our After School Program. The Watervliet Civic Center will implement the following procedures to ensure children are safely released. Please note that regular dismissal time will be approximately 2:00 PM for Pre-K children and 2:50 PM for children in Kindergarten to 5^th Grade.

The Watervliet Civic Center will utilize our automated message system to send a detailed automated recording about the program closure to your phone. Since this is the way we will notify you of any program closures, it is important that every family is signed up for the automated system. Please make sure you update us immediately any time telephone numbers and other contact information changes.
Program closure will also be posted on the Watervliet City School District's website; www.watervIietcityschools.org
The Watervliet City School District has a web-based messaging system called Parent Square. This system notifies parents via phone, email and text message of important district news and information, including school closings, delays and/or early dismissals. Parent Square automatically integrates contact information including phone numbers and email addresses from the district's management system, e-Schools Data, for parents/guardians of every student enrolled in Watervliet schools.
It will be the responsibility of the parent to make sure that their child arrives home safely.
Parents have the option of having their child picked-up by individuals listed on the pick-up list or take the bus home.

Please check one of the options listed below

My child will be picked-up by one of the individuals listed below.

My child is allowed to take the bus home.

Emergency Contact 2

Name

Phone #

Emergency Contact 2

Name

Phone #

Emergency Contact 2

Name

Phone #

If taking bus, please provide Bus #

I have read the program closure form and I am aware of the procedures that must be followed in the event that there is no Watervliet Civic Center After School Program.

PARENT/GUARDIAN SIGNATURE:

IN THE CASE OF AN EMERGENCY, I UNDERSTAND THAT EVERY EFFORT WILL BE

MADE TO CONTACT THE PARENT/GUARDIAN. IN THE EVENT, THE

PARENT/GUARDIAN CANNOT BE REACHED, THE CHILD WILL BE TRANSPORTED TO THE HOSPITAL PRE-SELECTED ON THE APPLICATION.

MY CHILD HAS PERMISSION TO ATTEND THE WATERVLIET CIVIC CENTER 2026

SUMMER RECREATION PROGRAM. HE OR SHE IS IN GOOD HEALTH AND CAN PARTICIPATE IN ALL ACTIVITIES AND EVENTS INCLUDING SWIMMING AND FIELD TRIPS.

I HAVE RECIEVED A COPY OF THE WATERVLIET CIVIC CENTER 2026 SUMMER RECREATION PROGRAM PARENT HANDBOOK. BY SIGNING THIS APPLICATION, I ACKNOWLEDGE THAT 1 UNDERSTAND AND AGREE TO ABIDE BY THE POLICIES AND PROCEDURES CONTAINED THEREIN.

GENERAL WAIVER OF LIABILITY: MY CHILD PLANS TO PARTICIPATE IN THE WATERVLIET CIVIC CENTER 2026 SUMMER RECREATION PROGRAM, BY SIGNING THIS RELEASE AND APPLICATION FORM, I UNDERSTAND THAT THE WATERVLIET CIVIC CENTER WILL NOT BE HELD RESPONSIBLE FOR INJURY TO PERSON OR PROPERTY.

PARENT/GUARDIAN SIGNATURE:

Thank you! Your submission has been received!
Have any questions regarding our program? Call and speak to Jonah Hatter - Program Coordinator 518-273-5922

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