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Public School District Operated School-Age Child Care - REGISTRATION FORM

After information is entered online below, you will receive an email with a PDF of the form that you had electronically submitted. Please print the completed PDF, scan, and email it to asost@mass.gov with the original signature of the Superintendent/Charter Leader/Collaborative Director. Upon receipt of the signed form, the Department of Elementary and Secondary Education (DESE) will process, and within one to two weeks will send an electronically signed confirmation letter to the school district. An updated Registration Form should be submitted if the information provided by district in this form changes. (Note: Form last updated in fall of 2021.)

BASIC PROGRAM INFORMATION

School District
Program Name
School(s) (Please include any schools that send students to this program/
Program Address
Program location type (e.g., school building, municipal building, community partner or other community building)
Program Director/Contact
Email
Phone
Month/year program plans to begin operating
Community-based partners, if applicable

Does your school district have community partner(s) that provide staffing for the program?

As you indicated that you have a community partner(s) that provide staffing for the program, please respond to the following:

Partner name(s)

Email of Program Coordinator / Contact: (an email with a PDF of the submitted form will be sent to this email address) *This question is required. This question requires a valid email address.

Additional Email: (If you would like a copy of the submitted form to be sent to another email address as well, please include it here.) This question requires a valid email address.

Program Description: Please provide a brief description of the program/services offered. (This may be from program flyer/recruitment materials. If available, you may upload a copy of your program flyer at the end of this form.)

STUDENTS SERVED

Please indicate the estimated number of students served at each applicable grade-level.

Space Cell	PK	K	1	2	3	4	5	6	7	8	9	10	11	12
School-Year	PK	K	1	2	3	4	5	6	7	8	9	10	11	12
Summer	PK	K	1	2	3	4	5	6	7	8	9	10	11	12

SCHEDULE OF OPERATION

Please provide the requested information for all that apply:

Space Cell	# hours/ day	# days/ week	# of weeks	Total # of hours
School-Year (before school)	# hours/ day	# days/ week	# of weeks	Total # of hours
School-Year (after school)	# hours/ day	# days/ week	# of weeks	Total # of hours
School Vacation Weeks	# hours/ day	# days/ week	# of weeks	Total # of hours
Summer	# hours/ day	# days/ week	# of weeks	Total # of hours

PROGRAM FEATURES

Services/Activities: Which of the following are components of the program/RLEC? (check all that apply)

Snack
Homework time/support
Enrichment/Academic Enrichment
Physical activity/wellness
Other - Write In Please enter an 'other' value for this selection.

Transportation: Please indicate how students travel to/from the program/RLEC. (check all that apply)

Provided by program/school
Parent pick-up/walk

Program Funding/Fees*: How is your program funded? (check all that apply)

Parent/family-pay*
Department of Elementary and Secondary Education grants (21st CCLC, ASOST)
Other Funding (local, private, etc.)

*If parents/families pay fees, does your program offer a sliding scale and/or scholarships for families that cannot afford the program/RLEC?

OTHER INFORMATION/ COMMENTS:

Please use this space for any additional information/comments, if applicable.

If available, you may upload a copy of your program flyer/handbook. (This is not required for registration.) Click Browse to find your file, click on the file, and then click Upload to begin upload process.

File: {{filename}} delete

Please select the correct school district type below as the type of attestation may differ:

ATTESTATION FOR SCHOOL DISTRICTS: Please read each attestation carefully. Check the box to the left to confirm that the district complies with the requirements and conditions described below.

The program has been authorized by the local school committee as required by G.L. c. 71, section 26A.
The school district maintains legal, fiscal and programmatic responsibility for the program.
The building in which the program is operated has met all applicable safety inspections.
The school district has reviewed DESE’s Careful Hiring Practices Advisory and will conduct the required background checks.
The program will follow the Quality Standards for Public School Operated School-Age Child Care Programs , as well as any subsequently released guidelines if applicable.
The program or RLEC will follow applicable school district policies and procedures.

ATTESTATION FOR CHARTER SCHOOLS AND COLLABORATIVES: Please read each attestation carefully. Check the box to the left to confirm that the charter/collaborative complies with the requirements and conditions described below.

The charter school or collaborative maintains legal, fiscal and programmatic responsibility for the program.
The building in which the program is operated has met all applicable safety inspections.
The charter school/collaborative has reviewed DESE’s Careful Hiring Practices Advisory and will conduct the required background checks.
The program is authorized by the governing board and meets any subsequently released guidelines if applicable.
The program will follow applicable charter school or collaborative policies and procedures.

     Superintendent/Charter Leader/Collaborative Director (Signature)*: _________________________________________________

     Date*: _________________________


*Upon receipt of the PDF version of this submitted form, please sign, scan and email with the signature of the Superintendent to asost@mass.gov.