Student's Name *
Student's Date of Birth * Grade * Pre Kindergarten Kindergarten First Grade Second Grade Third Grade Fourth Grade Fifth Grade Sixth Grade Seventh Grade Eighth Grade Care Needed * Before Care Payment Schedule * After Care Payment Schedule * Select the days you will need DAILY before care * Select the days you will need DAILY after care * Date to begin before/after care *
MM slash DD slash YYYY
Parent's Phone Parent's Email * Parent's Place of Employment * Work Phone * Physician *
Physician's Phone * Health History Emotional/Behavioral/Physical/Medical Issues * Please Describe * Does your student take medications? * List prescription medications that will need to be administered during aftercare hours * Food Allergies * Please specify nature of allergic reaction * Environmental Allergies * Please specify nature of allergic reaction * Persons Authorized to Pick Up
In case of emergency, please provide two different people with two different numbers
NameParent/Guardian with Legal Custody *
Phone * Relationship * Parent/Guardian or Primary Emergency Contact *
Phone * Relationship * Additional Contact *
Phone * Relationship * Required Documentation
Please upload required documents here. This can be completed now or later through the website.
All documents must be submitted at least 1 week prior to anticipated start date
Complete with at least 2 emergency contacts
Health Inventory, Part I Health Inventory, Part 2 Health Inventory, Blood Lead Testing Certificate Health Inventory, Immunization Record Medication Administration
Mandatory if child has asthma or allergies
To be completed by doctor
Asthma Action Plan
Mandatory if child has asthma
To be completed by doctor
Allergy Action Plan
Mandatory if child has allergies
To be completed by doctor
Code of Conduct * The Code of Conduct is to be read and agreed to by both parent/guardian and student participant.
UEC staff is committed to providing a safe, positive and structured environment for all children in the after school program. During childhood, children are learning to be in charge of their own behavior. We establish consistent, easy to understand limits. When out-of-bounds behaviors do occur, it is important for children to understand why the behavior is inappropriate and how to modify it. We work to prevent behavior problems by arranging the setting so that children work in small groups and have a choice of activities. The range of activities will give the child the freedom and ability to experience success and become self-directed. Children are encouraged to verbalize their feelings in order to learn to positively work through strong emotions. Teachers act as role models and encourage children’s appropriate behaviors. We will provide developmentally appropriate verbal explanations and guidance to help children gain confidence and social problem-solving skills. Appropriate behavior is expected and all efforts will be made to assist children in adjusting to the program setting.
• Use appropriate language at all times
• Cooperate with staff and follow instructions
• Respect yourself, peers, adults, materials and property
• Refrain from any disruptive behavior
• Be safe
Staff Response to Noncompliance of Expectations
• Redirecting the child’s activity
• Reasonably discussing the problem
• Planned ignoring
• Parent conference
• Development of Behavior Plan
UEC will operate under the following policies:
• Injurious treatment of children is not tolerated under any circumstances
• No corporal punishment, including spanking, will ever be used
• No child shall be subjected to cruel or severe punishment or verbal abuse, including those that are
shaming, frightening or humiliating
• No child shall denied food, toileting or rest privileges as punishments
• No harsh or profane language or implied threats promising physical punishment shall be used
UEC does not make it a practice to suspend or remove children from the program. However, UEC reserves the right to ask parents to find alternate child care arrangements for their child without prior notification, as deemed necessary for the safety of staff and program participants, including your own child(ren).
Children displaying chronic noncompliance of expectations or behavior that is upsetting or not conducive to the safety or physical or emotional well-being of another child will be suspended or expelled from care.
At no time will swearing, abusive language or physical violence or damage to property be allowed by children. Repeated use of inappropriate language and/or verbally abusive children will be withdrawn from the program. Physical violence and damage to property will result in immediate suspension or expulsion.
Discipline will be:
1. Individualized and consistent for each child
2. Appropriate to the child’s level of understanding
3. Directed toward teaching the child the acceptable behavior and self-control
1. Set clear and consistent limits
2. Offer straightforward explanations of limits
3. State limits in the positive rather than the negative
4. Provide appropriate and engaging materials
5. Allow children time to respond to expectations
6. Establish predictable routines
7. Provide sufficient, ordered and organized space to work and play
8. Acknowledge children’s’ feelings
9. Encourage self-control by providing meaningful choices
10. Using praise and encouragement for good behavior expectations
11. Remind children of behavior expectations daily
12. Redirecting behavior using positive statements
13. Cool down kit
14. Age-appropriate Conflict resolution charts
15. Provide opportunities for children to make amends Covid-19 Consent * I acknowledge the risks of Covid-19 and are allowing my child to attend before/after care
I acknowledge that I have independently reviewed the risks of exposure to COVID-19 in light of my child’s and my family’s personal health conditions, and I have decided to allow my child to attend camp with full knowledge of these risks and expectations described in this form.
United Educational Corp Programs (UEC) along with Maryland State Department of Education has developed health and safety protocols for in-person summer camp during the COVID-19 pandemic, based on the latest medical research, best practices, and input from the Baltimore City Health Department, our public health advisors, and other stakeholders. We are implementing the five key mitigation strategies recommended by the CDC for in-person learning including masking, social distancing, hand washing, cleaning and disinfecting, and contact tracing.
As a valued member of our UEC community, I commit to do my part to follow these protocols, so that we can help all our campers and staff be well and thrive. In addition, I agree to:
• Follow all rules for my child’s participation in before/after care
• Collaborate with staff to help ensure that my child follows all rules for wearing a mask or face-covering, washing hands frequently, and maintaining appropriate social distance
• Monitor my child’s health every day when they attend.
• Report to UEC if my child has a confirmed or suspected case of COVID-19.
• Not send my child to camp if they have COVID-19 or symptoms of a COVID-19 like illness, are waiting for test results, or have been in close contact (within 6 feet for at least 15 minutes total over a 24-hour period) in the past 14 days with anyone diagnosed with, or suspected of having, COVID-19.
• Ensure that, if my child becomes ill while attending camp, my child is picked up promptly
• If my child tests positive for COVID-19, I acknowledge that my child cannot return to camp until they receive a negative COVID-19 test or are released to return to camp from an authorized health care provider.
I understand that failure to comply with these rules may endanger our entire community and require UEC to take steps necessary to protect the welfare of my child, other students, and staff and may result in my child’s removal from before/after care. I acknowledge that I have independently reviewed the risks of exposure to COVID-19 in light of my child’s and my family’s personal health conditions, and I have decided to allow my child to attend before/after care with full knowledge of these risks and expectations described in this form. Consent * I have read and agree to the waiver
I acknowledge that I have read and understand UEC's policies as it relates to Registration, Procedures and Routines, Activity Schedule, Communication, Payment Procedures, Payment Schedule and Tuition. I understand a listed adult on the registration form must sign all students out daily. I understand that if my child is not picked up on time, I will be assessed a $1.00 per minute late fee thereafter, due at pickup. I acknowledge that my child and I have read and understand UEC’s rules and regulations. I understand that if my child is suspended/ expelled from UEC for any reason, it is at my expense and I am not entitled to a refund. I have insurance and recognize the risk of injury, illness or death. I, the legal guardian give permission for my child to participate in all activities offered by UEC, bus field trips, outside activities on or off site. I knowingly assume all risks and dangers inherent and incidental to the activities and thereby will not sue or hold BCPSS and/or United Educational Corp Programs or staff liable for any injuries or damages. I will administer all medication at home. UEC will only administer medications in emergency situations. I authorize UEC and staff to transport my child in the event of a field trip or medical emergency. I hereby grant UEC permission to use my child's likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the UEC and will not be returned.
I fully understand the release/waiver and will sign this document voluntarily.