2023-2024 Rising Rox Stars Program Registration
The Rising Rox Stars Program operates from October 16, 2023 to June 14, 2024 at Roxboro Road Elementary and Roxboro Road Middle Schools. The elementary school program hours are 8am-9am and 3:45pm-2:30pm. The middle school program hours are 2:45pm-5:30pm. Snacks and transportation will be provided. 

We are accepting new applications. You will receive a confirmation letter with the date of when your child can start in the program. Questions? Contact Chau Ly at cly@nscsd.org or 315-218-2734 (office) or 315-263-5284 (cell). 
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Student LAST Name *
Student MIDDLE Name
Student FIRST Name *
Student DATE OF BIRTH *
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Student's SCHOOL *
Required
Student's GENDER *
Student's STREET ADDRESS *
Student's CITY *
Student's ZIP CODE *
Phone Number (home or cell). Numbers only, no dashes. Example: 3152182034 *
EMAIL
Primary Language Spoken At Home *
Required
Student's GRADE  *
Required
Student's Race/Ethnic Group *
Required
Parent LAST Name *
Parent FIRST Name *
Parent Phone Number (home or cell). Numbers only, no dashes. Example: 3152182034 *
Please check the days of the week your child will attend the program. Morning program 8am-9am (RRE). PM - afternoon (after school). *
Required
Will your student need bus transportation to and from the program?  *
Required
Please list at least 2 emergency contact names and phone numbers (including relationship to student). *
If I am not available during emergencies, my child may be released to one of the following individuals. Please list name, phone number and relationship to student.
I give my student permission to walk alone at dismissal.
Clear selection
Please list important medical/health information about your student (i.e. allergies, asthma, etc...). Please indicate if your child has an IEP or a 504 plan.   *
I give my child permission to enroll and participate in the 2023-2024 Rising Rox Stars Program (funded by the 21st Century Community Learning Centers Grant). *
I understand that the following agreements and consents are not pre-conditions for approval to participate in the 2023-2024 Rising Rox Stars Program  (funded by the 21st Century Community Learning Centers Grant). *
I consent to emergency medical treatment for my child.
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I consent for my child to participate in interviews, the use of quotes, and the taking of photographs, movies, or videotapes by the program. I also grant the program the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the program and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
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I consent for my child to take part in field trips, away from the program site, under supervision.
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I understand the program may need additional permissions for situations such as transportation, medication, release of information, and field trips.
*
I provided information on my child’s special needs to the program to assist in the safety of my child.
*
I understand that information regarding my child’s special learning needs will be shared by my child’s school of enrollment with 2023-2024 Rising Rox Stars program staff on a need-to-know basis for my child’s educational benefit.
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I agree to review and update this information whenever a change occurs and at least once every year.
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I agree to talk to the program staff about my child’s progress and participation in the Rising Rox Stars program.
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If at any time I change my mind about my child’s participation (any or all aspects) in the program, I will contact the program director or site coordinator.
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I understand that my child’s academic, behavioral, attendance, and engagement information will be shared with the New York State Education Department and its lawful contractors, to measure and evaluate the quality and implementation of the Rising Rox Stars Program which is funded by the 21st Century Community Learning Center (21st CCLC) grant as well as the effectiveness New York State’s program in supporting student growth, as required by Title IV, Part B of the Every Student Succeeds Act (ESSA) [see generally sections 4205 (b) and 4203 (14)].
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I understand that my child and I may be asked to participate in surveys and/or interviews about the Rising Rox Stars Program (funded by the 21st CCLC grant) and its effects.
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I would like to opt-out and not participate in surveys and/or interviews.
Clear selection
By electronically signing below, I certify that all information above is true and correct to the best of my knowledge. Write in first and last name.
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Date of electronic signature.
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