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New Franklin School Student Name______________________________

1 Franklin Drive Student DOB_________________ Gender__ M __F

Portsmouth, NH 03801 Home Address: _____________________________

603-436-0910/ fax 603-427-2335 Grade/Teacher______________________________

What Days will s/he attend MC3? M T W TH F

2015-2016: MC3 After-School Activity/Sport Participant Emergency Form

Please return completed form to MC3 Program Director: Karley Lapierre, (603) 812-1760
Telephone Numbers Where Parent/Guardian may be reached. Please circle best # to use first.
Name:______________________________________ Name:_____________________________
Home # ____________________________________ Home#: ____________________________
Cell #: _____________________________________ Cell#:______________________________
Email: _____________________________________ Email _____________________________

Emergency contact, If parent/guardian cannot be reached, who will assume temporary responsibility:

Name ______________________________________ Name:_____________________________
Home #_____________________________________ Home #:____________________________
Cell#: ______________________________________ Cell #:______________________________
Relationship: ________________________________ Relationship: _________________________
Please list all people who have permission to pick up your child (Please Note: If a biological parent is NOT allowed to pick up his/her own child, a copy of the court order will be needed for MC3’s records.)

Does the student have any medical, behavioral or physical issues?

No:______ Yes: _______ Please list:_________________________________________________________
Does the student have any allergies? (bee sting, food, medication, environmental, etc.)
No:______ Yes: _______ Please list:_________________________________________________
Does student have Asthma? No_______ Yes________ Does the student require an inhaler?
No:______ Yes: _______ Please list:_________________________________________________
Is the student taking any medication?
No:______ Yes: _______ Please list:_________________________________________________
Does the student wear eyeglasses or contacts? No: ________ Yes: ________ (If yes, circle)
Does the student have an IEP or 504 Plan? No: __________ Yes: ___________ (If yes, circle which one)
Child lives with: ___Mother ___Father ___Both parents ___Shared custody with both parents

___Grandparents ___Guardian

Please check the total annual income of your household:
____0-$20,000 ____$20,001-$50,000 _____$50,001-$80,000 _____$80,001 and Above

How will your child be transported home from the MC3 program?

_____Parent/Guardian Pick-Up ______Late Bus _______Walker
Are you interested in sponsoring a student who is unable to pay for MC3 ($20.00 per week) ___Yes ___No
MC3’s late bus costs the MC3 program $46.00 per/day. Many students are in need of transportation from the program and rely on the late bus. Are you interested in contributing to the “late bus fund”? ___Yes ___No

If “Yes”, how much would you like to donate? _______________________________________

In the event of an early dismissal due to inclement weather or other unforeseen circumstance, I would like my child to go home via:
1. Bus: Bus #_________ 2. Walk______ 3. Picked up by: ___________________________

Signature Required for Liability Waiver/Medical Release/Photo Release/Educational/ Consent

I, the undersigned parent or guardian, do hereby agree to allow the individual named herein to participate in all MC3 activities and events. I understand that I release the Portsmouth School Department, Portsmouth Housing Authority, and MC3 from any liability in the event of injury or loss during this program. I release the Portsmouth School Department, Portsmouth Housing Authority, and MC3 from any liability in the event of injury or loss during any event. In case of injury to my child, I hereby waive all claims against the organizers and/or sponsors of these events. In case of illness or injury, I request the MC3 staff to contact me. If MC3’s staff member or its authorized representative is unable to contact me, I hereby authorize them to seek emergency medical treatment if needed. __________ Initial

I, the undersigned parent or guardian, grant a “Release of Information” to MC3 staff. MC3 staff may have access to my son/daughter’s Report Card, Interim Reports, Test Scores as well as Discipline and Academic Meeting Reports. In doing so, I understand that MC3 staff will honor and respect the privilege of confidential information about my son or daughter’s academic record. (Initials required) ___________ Initial
I, the undersigned parent or guardian, do hereby consent to the unrestricted use of my child’s name, portrait, picture, video or photograph, in order to document and/or publicize events, facilities, programs, trade or any other purpose. I waive the right to inspect or approve such completed portraits, pictures, photographs or advertising matter. ___________Initial

I, the undersigned parent or guardian, have read and will adhere to MC3’s pick up policy as well as the student discipline policy. ___________Initial

Signature of Parent/Guardian __________________________________ Date_____________

History of Making Classroom & Community Connections (MC3): In 2013, the Portsmouth School Department was awarded a 21st Century Community Learning Center (21CCLC) grant from the NH Department of Education. The 21CCLC grant allowed the Portsmouth School Department to collaborate with the Portsmouth Housing Authority to create an affordable afterschool program called Making Classroom and Community Connections (MC3). MC3 is designed to raise student academic achievement by providing students with academic enrichment opportunities that complement the students’ regular academic program. MC3 provides a wide range of high quality services to support student learning and development, including tutoring and mentoring, homework help, academic enrichment (e.g., hands-on science or technology programs), and community service opportunities, as well as music, arts, sports and cultural activities. All students who attend New Franklin School are eligible to participate in MC3 allowing for reasonable accommodations.

Hours of Operation:

MC3 is open Monday-Friday 2:40pm-5:45pm during the school year. MC3 will NOT be open during:
• School vacation weeks
Last day of school
• Last Early Release Day before the Holiday Break
• First two weeks of school
• Snow Days

Typical Daily Schedule:
2:40-3:00 - Attendance and Snack (USDA snack program used)
3:00-4:00 – Homework and Recess
4:00-5:00 – Enrichment Clubs
5:00 – Late Bus Departure
5:00-5:45 – Free Play

MC3 offers a “late bus” that leaves NFS at 5:00pm, Monday-Friday. The late bus is not offered on Early Release Days.
Enrichment Clubs:

Enrichment clubs are offered Monday-Thursday. Each set of enrichment clubs run for a duration of six weeks. Sign-up sheets for enrichment clubs are left in your families red hanging file folder a week prior to the start of the new club sessions. Different club options are offered for grades (K-2) and grades (3-5). Enrichment club sign-up sheets are also posted on NFS’s wiki space under the MC3 tab. Students are placed in the enrichment clubs in the order in which the sign-up sheets were received. Please be conscientious when you sign up your child for a club. If you know he/she will be picked up before 4:00pm, please do not register them for a club. This will keep spaces open for children who will be able to attend MC3 during club time. MC3 strives to offer a wide array of enrichment clubs. Last year alone, MC3 offered over 100 different enrichment clubs throughout the duration of the school year. Some examples of clubs that were offered were:

  • Computer Sciences

  • Cooking

  • Pickle Ball

  • Woodworking

  • Arts & Crafts

  • Nature and Natural Science

  • Rocketry

  • Soccer

  • World Culture

  • Literacy Club

  • Lego Club

  • Martial Arts

  • Crazy 8’s Math Club

  • Code Breakers

MC3’s Cost:
Students’ families will be charged using a sliding scale based on their household income:

Family Income

Weekly Cost

(per child)

$0 - $20,000


$20,001 - $50,000


$50,001 - $80,000


$80,001 - Above


Please Note: No child will be turned away from the program due to the inability to pay. MC3 staff will work with your family on an individual basis to set up a payment plan that will suit your families’ budget.

Scholarships: Some scholarships are given to individual families who are facing financial hardship. Please Note: Any family who feels they can’t afford to pay the monthly fees will be required to fill out a scholarship application form. This form needs to be completed before any family will be considered for a scholarship. All families are encouraged to contribute what they can to help pay for the sustainability of the program.

Families will be given an invoice at the beginning of every month for the up-coming month’s programming cost. The invoices will be left in your families red hanging file folder located in the hallway near the gymnasium and library. We accept cash or checks. If possible, when paying with cash, please have the correct change. When paying by check, please make checks payable to: Portsmouth School Department. Payments can be paid to MC3 staff member during programming time, placed in MC3’s mailbox located outside of New Franklin School’s main office or mailed to:

New Franklin School


1 Franklin Drive

Portsmouth NH 03801


Parent Pick-Up Policy:

Parents will be required to use the security button located to the left of the main door at NFS in order to gain access to the building. After entering, parents should go to the cafeteria where an MC3 staff member will assist with dismissing your child. If an MC3 member is not available during “club times from 4:00-5:00”, the locations of the club offerings are displayed on the large white board in the cafeteria. Groups are separated into two categories grades K-2 and grades 3-5.

Students must be picked up or babysitting arrangements must be made no later than 5:45pm during the school year. Time is kept by staff’s cell phone. Parents/guardians will be charged $10.00 for every 15 minutes after 5:45pm that your child/ren is at the program. Additionally, any portion thereof will be considered a full 15-minute increment. For example, if a student is picked up at 5:46pm a payment of $10.00 is due, at 6:01pm a payment of $20.00 is due etc. Payments may be made at pick up or a bill will be mailed home. Scholarships are NOT available for late fees and your child will not be permitted back into the program until the late payment has been paid.

  • 1st Late Violation: Will be treated as an “oops”.

  • 2nd Late Violation: Fee will be charged, a warning will be made, a late payment must be made before student is allowed back in the program.

  • 3rd Late Violation: Fee will be charged, the last warning will be made, a late payment must be made before student is allowed back into the program.

  • 4th Late Violation: Student will be dismissed from the program for the remainder of the fiscal year (July 01, 2014-June 30, 2015) and late payment must be made.

Early Release Days:
For an additional $20.00 charge, MC3 provides programming on Early Release Days until 5:00pm. Early Release Days are run differently due to the extended programming duration. There is no late bus offered on Early Release Days. You will be required to register for the Early Release Days the day before the Early Release Day. This allows MC3 staff time to notify teachers of dismissal plans the night before programming. Please note that space is limited due to the availability of staff during the earlier time of operations.


Discipline Procedures:

In the event of “misbehavior” by a student, MC3 will follow the “3 Red Cards and You’re Out” system. MC3 staff reserve the right to give cards as needed as well as remove a child from the program if a behavior situation is severe enough or the safety of participants are compromised. If students display disruptive/disrespectful/unsafe behavior, they will first be given a “Yellow Card” just like a soccer game. The “Yellow Card” will stay on file. If the students display disruptive/disrespectful/unsafe behavior again, they will be given a “Red Card” automatically. If an infraction is severe enough, MC3 staff reserves the rights to give a Red Card immediately, even if a yellow card is not on file. The following actions will be taken when misbehavior occurs:
1st Red Card: Parents will be notified and be given a disciplinary form that they must sign. The child will be reminded of the rules; a suspension may be issued depending on the severity of the infraction.
2nd Red Card: Parents will be notified and be given a disciplinary form that they must sign. The child will be reminded of the rules; a suspension may be issued depending on the severity of the infraction.
3rd Red Card: Parents will be notified and be given a disciplinary form that they must sign. The child will not be permitted back in the program for the remainder of the school year.
Educational Consent Required:

Due to the requirements of the grant that was awarded by the NH Department of Education, MC3 staff is required to monitor each student’s academic achievement and offer additional support as needed.

The program is designed to be a learning center with the goal of raising students’ academic achievement.
Group Text/Email Alerts/Reminder System:

MC3 uses a type of announcement software called Remind101 which sends out group texts and/or emails for anyone who would like to receive up-to-date information regarding MC3’s program. MC3 uses this system to alert parents if there is a cancellation due to unforeseen circumstances such as inclement weather, power outages, staffing shortages, etc. Additionally, we will remind parents when “enrichment club sign-up forms are available”. You may sign up via text messaging, email or both. If you are interested in signing up for alerts and reminders via text, please text:

To: (929) 227-6651
Write Message: @mc3


Via email: (Visit this link)

Please Note: This is only a messaging system and you will not be able to reply or call the system back. If you would like to contact MC3 staff, please call 603-812-1760, or email Karley Lapierre, Program Director at

Notification Required if Child will be Absent:

If a child will be absent from MC3, it is extremely important to send a written note to Mrs. Lister (NFS secretary) or the student’s teacher in the morning. Advance notice is important to ensure a smooth dismissal plan for the afternoon. Please remember that Mc3 serves over 100 NFS students, therefore, it is imperative to give advance notice for dismissal plans. Last minutes changes are extremely difficult to keep up with. By giving advance notice, it assists with student safety and prevents MC3 staff from searching for students who were scheduled to attend programming but did not show up. It allows MC3 staff to focus on students who ARE in attendance instead of focusing on children who are NOT in attendance. Thank you in advance with for your assistance.

Contact Information:

Please feel free to call/text Karley Lapierre, Program Director at 603-812-1760, with any questions/concerns. If no one is available to receive your call, please leave a message on the voicemail and we will return your call as soon as possible.

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