Important: Additional children at the same location can be added using the same application. If you have children at more than one location or household they must be submitted on separate applications.
Note: Sheboygan Falls and Lake Country Academy are not accepting applications at this time.
Select a Location:* How many children are you applying for this location?* 1 2 3 4
Your selection is an after school program.
Before & After School Program:* Member Information Child Name:*
First
Last
Age:*
Birth Date:*
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 your child have access to reliable internet service in the home?* School Information 2020-21 School Year Grade:*
School Name:*
Primary Teacher Name:*
School Lunch Program:* Does your child have an individual Education Plan (IEP) or a 504 Plan?* Are you applying for fee assistance for the School Year 2020-21 program?* If accepted, a copy of your free/reduced lunch approval letter from the school district must be provided.
Explain Special Circumstances:* (provide important information regarding any sudden income loss or financial hardship)
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:*
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 your child have access to reliable internet service in the home?* Child 2 - School Information 2020-21 School Year Grade:*
School Name:*
Primary Teacher Name:*
School Lunch Program:* Does your child have an individual Education Plan (IEP) or a 504 Plan?* Are you applying for fee assistance for the School Year 2020-21 program?* If accepted, a copy of your free/reduced lunch approval letter from the school district must be provided.
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:*
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 your child have access to reliable internet service in the home?* Child 3 - School Information 2020-21 School Year Grade:*
School Name:*
Primary Teacher Name:*
School Lunch Program:* Does your child have an individual Education Plan (IEP) or a 504 Plan?* Are you applying for fee assistance for the School Year 2020-21 program?* If accepted, a copy of your free/reduced lunch approval letter from the school district must be provided.
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:*
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 your child have access to reliable internet service in the home?* Child 4 - School Information 2020-21 School Year Grade:*
School Name:*
Primary Teacher Name:*
School Lunch Program:* Does your child have an individual Education Plan (IEP) or a 504 Plan?* Are you applying for fee assistance for the School Year 2020-21 program?* If accepted, a copy of your free/reduced lunch approval letter from the school district must be provided.
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:*
Employer:*
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:
Military Involvement Is/Was either parent/guardian in the Armed Forces?* Branch:*
Emergency Contact/Authorized Pick Up Must be someone OTHER THAN PARENT/GUARDIAN.
Contact #1:*
First
Last
Relationship to Member:*
Primary Phone:*
Primary Phone Type:* Home Cell Work
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.
Policy and Waiver Information PLEASE READ CAREFULLY
OPEN DOOR POLICY:
SCHOOL YEAR ORIENTATION:
**REQUIRED**
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:*
MM slash DD slash YYYY
Email This field is for validation purposes and should be left unchanged.
