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Student Application

Student Application Form

Please fill out the form below, or download our Student Application Form, print, fill out, and return to us.

We will contact you directly when your child is accepted into the program.

All paperwork must be turned in for the child to attend the program.

"*" indicates required fields

Student Name*

First Last

Gender*

Male

Female

Race*

Age*

Birth Date*

MM slash DD slash YYYY

Teacher

Grade

School

Parent / Guardian*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone*

Work Phone

Work Location

Email*

May we call you there, or is there someone else we should contact in an emergency?*

How will your child be getting to the Flickinger Learning Center?*

Walking from Home

Dropped off by parent or someone else designated by the parent

Utilizing the FLC-NET transportation system to 413 Mulberry from their home school (excluding Jefferson) - If Yes, a transportation waiver must be signed.

Other

Person designated to drop off child*

Student Transportation Waiver

If your child is ill or will not be using the services on any given day you MUST contact Flickinger Learning Center at 563-288-9000 to let us know. If you do not, transportation may be revoked. Your child must maintain good attendance to continue to receive transportation services as there are limited spaces available.

If services are canceled for any reason, Flickinger Learning Center will make contact with you prior to the end of the school day.

With this signature, I give my child permission to utilize the Non-Emergency Transport system from school to Flickinger Learning Center located at 413 Mulberry Ave. I understand that I must pick up my child from their home school.

I have read and understood the above Transportation Waiver statements and agree:*

Yes

How will your child leave the center?*

Walking alone

Walking with someone designated by the parent

Picked up by the parent/guardian

Other

Person designated to pick up child*

Anyone else who has permission to pick up your child

Home phone of person with permission

Cell phone of person with permission

Name of anyone who DOES NOT have permission to pick up your child

First Last

EMERGENCY CONTACT Name*

First Last

Relationship to student*

Emergency Home Phone*

Emergency Cell Phone*

Backup EMERGENCY CONTACT Name*

First Last

Backup Emergency Relationship to student*

Backup Emergency Home Phone*

Backup Emergency Cell Phone*

With what subjects does your student need special help?*

Your signature on this form will give the Flickinger Learning Center authorization to exchange information (FAST, MAP; attendance) with the Muscatine Community School District. You may revoke this authorization, in writing, at any time. (Please be sure you have read and understood this document before signing.) Any and all personally identifiable information regarding children receiving special education services funded under the IDEA is protected from unauthorized disclosure under the Family Educational Rights and Privacy Act (FERPA) All special education providers comply with these procedures.

Is there anything about your child we need to know? (learning habits/medication/etc.)*

May we use your child's photo in publications concerning the Flickinger Learning Center?*

Yes

Are there any games or activities in which your child should not participate?*

Any allergies or other health conditions we need to know about? If yes, please list and provide the emergency procedures we should follow:*

Computer Information: Your child will have access to the Internet at the Learning Center. We monitor the use and have provided safety blocks, but there is always a possibility of them seeing inappropriate material. We will do everything in our power to protect your children.

Does your child have an Individualized Education Plan (I.E.P.) during the school day?*

Yes

Please arrange a private meeting with the site coordinator prior to your child starting the Flickinger program. This will help to ensure we can adequately meet your child’s needs.

I.E.P Type*

Academic

Behavioral

Does your child take any daily medications?

Does your child qualify for free or reduced lunch at school?*

Yes

Parents/Guardians: I have read and answered every question and agree that my child can participate in the After-School Program at Flickinger Learning Center. If there are any questions or concerns about my child I can be contacted and will help in any way I can.*

Yes

This field is for validation purposes and should be left unchanged.

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Contact Info

Flickinger Learning Center
413 Mulberry Avenue
Muscatine, IA 52761
(563) 288-9000

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Flickinger Learning Center is a 501(c)3 exempt organization (public charity) as defined by the IRS and eligible to receive tax-deductible donations (55-0870683)