Important: Additional children in the same age category (Youth or Teen) can be added using the same application. If you have both a Youth and a Teen they must be submitted on separate applications.
Age Group:* How many children are you applying for this age group?* 1 2 3 4
Member Information Child Name:*
First
Last
Age:*
Birth Date:*
Date Format: MM slash DD slash YYYY
Primary Home Address:*
Gender:* Race:* Black White Asian Native American Multi-Racial Other
Ethnicity:* Hispanic Non-Hispanic
Who does the child live with?* Both Parents Joint Custody Foster Family Mom Only Dad Only Other
Explain:*
Does the child have access to his/her own laptop or tablet for Virtual Learning?* Does the child have access to WIFI in the home?* School Information 2019-20 School Year Grade:*
School Name:*
Primary Teacher Name: (optional)
Primary Teacher Phone: (optional)
Primary Teacher Email: (optional)
School Lunch Program:* Does your child have an individual Education Plan (IEP) or a 504 Plan?* Medical Information Check all medical conditions your child experiences:* Please explain:*
Does your child have any allergies?* List all allergies:*
Does your child have an Epi Pen?* Does your child take any medications?* List all medications:*
Child 2 - Member Information Child Name:*
First
Last
Primary Home Address:*
Age:*
Birth Date:*
Date Format: MM slash DD slash YYYY
Gender:* Race:* Black White Asian Native American Multi-Racial Other
Ethnicity:* Hispanic Non-Hispanic
Who does child 2 live with?* Both Parents Joint Custody Foster Family Mom Only Dad Only Other
Explain:*
Does the child have access to his/her own laptop or tablet for Virtual Learning?* Does the child have access to WIFI in the home?* Child 2 - School Information 2019-20 School Year Grade:*
School Name:*
Primary Teacher Name: (optional)
Primary Teacher Phone: (optional)
Primary Teacher Email: (optional)
School Lunch Program:* Does your child have an individual Education Plan (IEP) or a 504 Plan?* Child 2 - Medical Information Check all medical conditions child 2 experiences:* Please explain:*
Does child 2 have any allergies?* List all allergies:*
Does your child have an Epi Pen?* Does child 2 take any medications?* List all medications:*
Child 3 - Member Information Child Name:*
First
Last
Primary Home Address:*
Age:*
Birth Date:*
Date Format: MM slash DD slash YYYY
Gender:* Race:* Black White Asian Native American Multi-Racial Other
Ethnicity:* Hispanic Non-Hispanic
Who does child 3 live with?* Both Parents Joint Custody Foster Family Mom Only Dad Only Other
Explain:*
Does the child have access to his/her own laptop or tablet for Virtual Learning?* Does the child have access to WIFI in the home?* Child 3 - School Information 2019-20 School Year Grade:*
School Name:*
Primary Teacher Name: (optional)
Primary Teacher Phone: (optional)
Primary Teacher Email: (optional)
School Lunch Program:* Does your child have an individual Education Plan (IEP) or a 504 Plan?* Child 3 - Medical Information Check all medical conditions child 3 experiences:* Please explain:*
Does child 3 have any allergies?* List all allergies:*
Does your child have an Epi Pen?* Does child 3 take any medications?* List all medications:*
Child 4 - Member Information Child Name:*
First
Last
Primary Home Address:*
Age:*
Birth Date:*
Date Format: MM slash DD slash YYYY
Gender:* Race:* Black White Asian Native American Multi-Racial Other
Ethnicity:* Hispanic Non-Hispanic
Who does child 4 live with?* Both Parents Joint Custody Foster Family Mom Only Dad Only Other
Explain:*
Does the child have access to his/her own laptop or tablet for Virtual Learning?* Does the child have access to WIFI in the home?* Child 4 - School Information 2019-20 School Year Grade:*
School Name:*
Primary Teacher Name: (optional)
Primary Teacher Phone: (optional)
Primary Teacher Email: (optional)
School Lunch Program:* Does your child have an individual Education Plan (IEP) or a 504 Plan?* Child 4 - Medical Information Check all medical conditions child 4 experiences:* Please explain:*
Does child 4 have any allergies?* List all allergies:*
Does your child have an Epi Pen?* Does child 4 take any medications?* List all medications:*
Parent/Guardian Information All parents/guardians listed are allowed to pick-up the child(ren) named above unless access is prohibited or restricted by a court order (provided to Club).
Primary Parent/Guardian:*
First
Last
Relationship to Member:*
Home Address:*
Primary Phone:*
Primary Phone Type:* Home Cell Work
Secondary Phone: (optional)
Secondary Phone Type: (optional) Home Cell Work
Email Address: (optional)
Employer:*
Position:*
Household Income* Select Income Range $0 - $24,999 $25,000 - $29,999 $30,000 - $34,999 $35,000 - $34,999 $40,000 - $44,999 $45,000 - $49,999 $50,000 - $54,999 $55,000 - $59,999 $60,000 or more
Number in Household:*
Other Parent/Guardian (optional) Full Name:
First
Last
Relationship to Member:
Home Address:
Primary Phone:
Primary Phone Type: Home Cell Work
Secondary Phone:
Secondary Phone Type: Home Cell Work
Email Address:
Employer:
Position:
Military Involvement Is/Was either parent/guardian in the Armed Forces?* Branch:*
Emergency Contact/Authorized Pick Up These individuals must be people other than the parent/guardian who also has authorized pick up permission
Emergency Contact #1:*
First
Last
Relationship to Member:*
Primary Phone:*
Primary Phone Type:* Home Cell Work
Emergency Contact #2:*
First
Last
Relationship to Member:*
Primary Phone:*
Primary Phone Type:* Home Cell Work
YOUTH ONLY: Option for Authorized Pick-up* You can choose to require that your child only be allowed to leave the Club under the supervision of individuals you have authorized by selecting ‘yes’ to the authorized pick up option. I understand that if authorized pick up is selected, only contacts listed on this application or the Authorized Pick Up form, will be allowed to pick up your child from the Club. These contacts will be verified at time of pick up.
Youth Only: Summer Program Attendance Will your child(ren) be participating in Summer School?* Summer Program Site Preference:* Summer Program Options:* Due to safety modifications only a limited number of applicants will be accepted. Indicate your choices below:
First Choice:* Second Choice:* Third Choice:* On average, what days of the week will your child(ren) be attending the summer program?* Notes for Multiple Children: (optional) If you are applying for multiple children and attendance answers are different for each child, please explain here.
Youth Only: Summer Program Fee Assistance Financial assistance is available based on 2019-20 School Year eligibility for Free/Reduced lunch.
Eligibility
Half Day Option Full Day Option
Cost per Child Cost per Family (max) Cost per Child Cost per Family (max)
Standard Rate $125 $300 $200 $525
Qualify for REDUCED Lunch $60 $150 $100 $275
Qualify for FREE Lunch $35 $80 $60 $150
Special Circumstances* Based on ability to pay
Are you applying for fee assistance for the summer program?* *Explain Special Circumstances: (optional) Provide important information regarding any sudden income loss or financial hardship.
Teen Only: Summer Program Attendance Summer Program Site Preference:* Notes for Multiple Children: (optional) If you are applying for multiple children and attendance answers are different for each child, please explain here.
Annual Teen Membership Fee: $20 for new/renewing members.
Summer Program Daily Options:
Due to safety modifications only a limited number of teens will be allowed at a time for each program. Sign up
for attendance will be made available in two weeks blocks.
Policy and Waiver Information PLEASE READ CAREFULLY
OPEN DOOR POLICY:
SUMMER ORIENTATION:
**NEW THIS YEAR**
SUMMER PROGRAM COMMUNICATIONS:
MEDICAL EMERGENCY:
Liability:
PHOTOS/VIDEOS:
LATE PICK-UP POLICY:
TRAVEL:
PROGRAM PARTICIPATION:
SURVEY:
TECHNOLOGY:
ASSUMPTION OF THE RISK AND WAIVER OF LIABILITY RELATING TO CORONAVIRUS/COVID-19:
I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION.
Parent/Guardian Signature:* Signer's Printed Name:*
First
Last
Signed Date:*
Date Format: MM slash DD slash YYYY
Phone This field is for validation purposes and should be left unchanged.
