Roxy Aftercare 2026-2027 School Year

Join us for the 2026-2027 school year at Roxy After-School!

Roxborough Church strives to provide affordable, Christian children’s programming to the Northwest section of Philadelphia. We do this by offering early childhood education through our preschool, education assistance through our afterschool program, and planned activities through our summer camp.

In order for your child to participate in these programs, you must complete this application. All information is required in order for your student to be registered and attend.

This application and the accompanying $30 fee is the first step in registration. Once your application has been processed you will receive an invitation to join Brightwheel, our system for parent communication and billing, if you do not yet have an account with us. Your child's spot in Roxy After-School will not be secured until the application is submitted and after you have received a confirmation email from education@rpcnet.org

If you do not have a recent health report for your child on file with us, you can download the form here.

Roxy After School will primarily follow the Philadelphia School District scheduling. Exceptions will be made for the specialized charter school and Christian school calendars. Roxy After School staff will pick up students in accordance with all hours of school operation (i.e. full days, half days, and early dismissal). There is a possibility that your child will be transported by school district bussing. This decision will be made late summer.
Roxy After School will act in accordance with The Philadelphia School District’s cancellation policy. Should schools be closed for any reason (i.e. snow, heat, etc.), Roxy will also be closed. In the event of an early dismissal due to weather, Roxy staff will pick up students from the schools and will supervise the students until we close at 6:00 PM. We will not remain open during our regular hours (3-6PM).

On a day school has been in session, Roxy may cancel programming or close its programs early due to unsafe weather conditions. You will receive notification via email and the Brightwheel app. In the event of an early closure due to a weather emergency, parents are required to arrange for pick up of their child(ren) by the specified closure time.
If you have any questions, please contact us at education@rpcnet.org . We are looking forward to a fun-filled year with your student!

Roxborough Church
8230 Ridge Ave
Philadelphia, PA 19128
Telephone: 215-483-2762

Roxborough Church is an equal opportunity provider.
We do not discriminate against on the basis of race, religion or gender.

Student Information

Name

Birthdate:

Gender:

Primary School:

2026-2027 Grade:

Address

Parent/ Guardian Information 1

Name:

Relationship to Child:

Phone

This address will receive a confirmation email

Address

Parent/Guardian Information 2

Name:

Relationship to Child

Phone

This address will receive a confirmation email

Address

Emergency Contacts

Parents are the first emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. These individuals will also be approved pickups. Any person listed should be able to assist in contacting you, able to take responsibility for the child in case the parent/guardian cannot be contacted, and should be at least 18 years of age.

Name:

Relationship to Child:

Phone

Name:

Relationship to Child

Phone

Name:

Relationship to Child

Phone

Medical Information

Name of Physician:

Phone

Does your student have any medical conditions/disabilities?

Does your student have any allergies?

Does your student have an IEP?

IEP File

Upload (8MB)

Medical Care and First Aide Consent

My initials below authorize staff of Roxborough Church who are trained in the basics of first aid to give my child First Aid when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize Roxborough Church to transport my child to the nearest medical care facility and to secure necessary medical treatment for my child. I understand that I assume all financial responsibility for any treatment or injuries sustained by my child while he/she is in Roxborough Church care.

Child's Name

Parent's Signature:

Today's Date:

Administration of Medication Consent Form

All prescriptions and nonprescription medications shall be maintained with the child's name and shall be dated.
2. Prescriptions and nonprescription medications must be stored in the original bottle with unaltered label. Medications requiring refrigeration must be properly stored.
3. Prescription and nonprescription medication shall be administered in accordance with the label directions.
4. Written consent must be provided from the parent, permitting Roxborough Church staff to administer medications to the child. Instructions shall not conflict with the prescription label or product label directions.

Is your child currently on any medication that needs to be administered during program hours? If yes, please explain and include directions for administration *

My Signature below authorizes the staff of Roxborouhg Church to administer medication that is listed above and any additional medication as needed.

Child's most recent health form

Upload (8MB)

Photograph/Media Release Authorization on Behalf of Roxborough Church

Child's Name:

I give permission to have my child appear in any media coverage (tv, newspaper articles, photographs, website, etc) on behalf of Roxborough Church *

Yes No

Parent/ Guardian Agreement

General Policies:
1. I am enrolling my child in Roxborough Church's programs.
2. I understand there is an application fee of $30.
3. I understand there is a tuition fee which is due by the due date via brightwheel or by check. Failure to pay could result in receiving a $15 late fee. After multiple late payments, my child may lose their spot in the program.
4. I understand that Roxborough Church will be providing Roxy Afterschool from the hours of 3:00 pm - 6:00 pm.
5. I understand that my child will not be dismissed from the program without being picked up by a parent designated adult.
6. I understand there will be a $25 fee will be added every 15 minutes for late pick-ups.
7. I understand that disrespect, fighting, physical and verbal aggression will not be tolerated in this program. I understand that my child could lose their position in the program and may be discharged immediately for such actions.
8. I understand that if a medical emergency arises, program staff will attempt to contact parents or the emergency contact that I have indicated. It is the parent's resonsibility to notify the staff if this information changes. If immediate medical attention is necessary, an ambulance or emergency vehicle may take my child to the hospital.
9. In case of illness, I understand that my child may not be permitted to attend the program. If staff feels that a child has a contagious disease, he/she may not return to the program without a doctor's note.
10. In order for my child to be considered for this program I understand that I must complete all enrollment paperwork and health assessments.
11. I understand that Roxborough Church's programs are faith-based (Christian).
12. I have received complete program information (handbook) at the time of enrollment (PA Code 3270.121, 3280.121, 3290.121).
13. I agree to update the emergency contact and parental agreement when changes occur or every 6 months at a minimum (PA Code 3270.124, 3280.124, 3290.124).

Parent/Guardian Signature:

Today's Date:

Non-Discrimination in Service

SUBJECT: Nondiscrimination in Services

TO: Parents/Guardians

FROM: Jessica Peale; Director of Education

Admissions, the provisions of services and referrals of clients shall be made without regard to race, color, religious creed, disability, ancestry, national origin (including limited English proficiency), age or sex.
Program Services shall be made accessible to eligible persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to, equipment redesign, the provision of aides and the use of alternative service delivery locations. Structural modifications shall be considered only as a last resort among available methods.
Any individual/client/patient/student (and/or their guardian) who believes they have been discriminated against, may file a complaint of discrimination with:

Roxborough Church
8230 Ridge Ave.
Philadelphia, PA 19128

Commonwealth of Pennsylvania Department of Human Services Bureau of Equal Opportunity
Room 225, Health & Welfare Building P.O. Box 2675
Harrisburg, PA 17105

U.S. Department of Health and Human Services
Office for Civil Rights
Suite 372, Public Ledger Building 150 South Independence Mall West
Philadelphia, PA 19106-9111

Parent/Guardian Signature:

Today's Date:

Dismissal, Discipline, and Discharge Policy

Children are not permitted to arrive alone and must be signed in by an adult.

Children are only permitted to be signed out by an approved pickup over the age of 18.

The fee for late pick up is $15 per 15 minute interval. Excessive lateness will be reviewed.

Children are not permitted to bring any toys from home.

A child who displays chronically disruptive behavior may be suspended or discharged at the discretion of the Director. Students will follow the behavior plan when incidents occur: 3 day suspension after the first incident such as physical violence or adult language as well as a meeting with Director before student's return. Second incident: Week Suspension with second meeting with Director before student's return. Third incident: Explusion.

Unacceptable Behavior of the Participant:
1. Ignoring or disobeying the rules during the program times

Parent's Signature:

Today's Date:

Payment

Payment $30.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Roxy Aftercare 2026-2027 School Year

Description

Please Fix the Following