Lights On Registration Form


PLEASE NOTE:  You only have to complete one registration per student per year
Please notfiy office if your student's contact information and/or schedule changes.

 

Please provide the following information as completely as possible.  If you have any questions please contact the Lights On in Lander office at 332-4240
School Attending
 
School Attending
 
Early Bird, Power Hour and Enrichment Schedule: Please check all days that apply.
 MondayTuesdayWednesdayThursdayFriday
EARLY BIRD (7:00-8:00AM)
POWER HOUR (3:15-4:30PM; Wed: 2:15-4:30PM)
ENRICHMENT (4:30-5:30PM)
 YesNo
May we photograph and/or video your child during Lights On Activities?
Would you be interested in sitting on our Community Advocacy Council?
Bus Drop Off Location (Bus leaves Lights On at 5:30 p.m.)

NOTE: New this school year, bus students won’t leave Lander until 6:15PM due to picking up students at LMS and LVHS before starting bus routes.

My student will be WALKING home. He/she will be allowed to leave program at:

Dear Parent(s)/Guardian(s):

Your child is taking part in out-of-school time programming funded by the U.S. Department of
Education and the 21st Century Community Learning Centers program. The Wyoming Department of Education (WDE) requests your permission to collect classroom behavior information from your child’s teacher(s). 

In past years, the WDE also collected grade reports from your child’s teacher(s).  This year, the WDE is utilizing a new database system that will aggregate data which is already collected by the WDE.  Data will include PAWS scores, MAP scores, Statewide Youth Risk Behavior Survey (YRBS) results, and 636 data.  

The classroom behavior data the WDE will be requesting from your child’s teacher will be tracked using WISERID numbers. This data will be aggregated at the state level to protect your child’s identification.   Only researchers and the Wyoming Department of Education will have access to these data.  If you do not give WDE permission to collect data from your child’s teacher, it will not affect your child’s participation in the 21st Century Community Learning Centers program.

Data is collected so that the out-of-school time program your child is attending can be evaluated by
researchers as well as state and federal policy makers.  Your child’s data will help researchers and policy makers evaluate Wyoming 21st Century Community Learning Centers’ effectiveness. In order for policy makers to spend your tax dollars wisely, they need to know which programs are successful and which are not. The out-of-school time program your child attends needs to be able to provide evidence of its effectiveness if it is to continue to receive state and federal funding. Teacher reports documenting your child’s academic achievement are critical to this process.

A copy of the teacher report can be obtained from and questions or concerns can be directed to:

Karen Bierhaus, Program Manager
21st Century Community Learning Centers
Wyoming Department of Education
2300 Capitol Avenue, Hathaway Building, 2nd Floor
Cheyenne, Wyoming 82002
Phone: (307) 777-5332
Email: karen.bierhaus@wyo.gov
Fax: (307) 777-6234

Please let us know only if you do not wish to have your child’s teacher(s) complete a report and return this form to program providers.  I have read this form and understand that my child’s teacher(s) will be completing reports on my child’s grades and classroom behavior.  I understand that my child’s participation in the evaluation of the programming is voluntary and that my refusal to allow my child’s teacher(s) to complete the report will not involve penalty or the loss of benefits to my child of any kind.


By filling out the following application, I agree to the following terms:
I hereby authorize Fremont County School District #1 to release pertinent information (i.e., Emergency Information, Health Information & Personal Information) regarding the above named student(s) to Lights On in Lander personnel as needed.  I also authorize officials to take whatever action is deemed to necessary in their judgement for the health of my child.  I will not hold them financially responsible for the emergency care and/or transportation of my child.
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