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.
Select a Location:* How many children are you applying for this location?* Make a selection 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:* Specify
Race:* Make a selection Black White Asian Native American Multi-Racial Other
Ethnicity:* Make a selection Hispanic Non-Hispanic
Who does the child live with?* Make a selection Both Parents Joint Custody Foster Family Other Parent/Guardian Prefer not to answer
Explain:*
Parent/Guardian Name:*
Additional Adult in Household (if applicable): ie, Parent's Boyfriend/Girlfriend
School Information 2023-24 School Year Grade:* Please make a selection K-5th K 1st 2nd 3rd 4th 5th
2023-24 School Year Grade:* Please make a selection K-8th K 1st 2nd 3rd 4th 5th 6th 7th 8th
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 2023-24 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:* If families choose not to disclose a health condition, staff still must respond, but the response may be tempered.
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:* Specify
Race:* Make a selection Black White Asian Native American Multi-Racial Other
Ethnicity:* Make a selection Hispanic Non-Hispanic
Who does child 2 live with?* Make a selection Both Parents Joint Custody Foster Family Other Parent/Guardian Prefer not to answer
Explain:*
Parent/Guardian Name:*
Additional Adult in Household (if applicable): ie, Parent's Boyfriend/Girlfriend
Child 2 - School Information 2023-24 School Year Grade:* Please make a selection K-5th K 1st 2nd 3rd 4th 5th
2023-24 School Year Grade:* Please make a selection K-8th K 1st 2nd 3rd 4th 5th 6th 7th 8th
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 2023-24 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:* If families choose not to disclose a health condition, staff still must respond, but the response may be tempered.
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:* Specify
Race:* Make a selection Black White Asian Native American Multi-Racial Other
Ethnicity:* Make a selection Hispanic Non-Hispanic
Who does child 3 live with?* Make a selection Both Parents Joint Custody Foster Family Other Parent/Guardian Prefer not to answer
Explain:*
Parent/Guardian Name:*
Additional Adult in Household (if applicable): ie, Parent's Boyfriend/Girlfriend
Child 3 - School Information 2023-24 School Year Grade:* Please make a selection K-5th K 1st 2nd 3rd 4th 5th
2023-24 School Year Grade:* Please make a selection K-8th K 1st 2nd 3rd 4th 5th 6th 7th 8th
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 2023-24 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:* If families choose not to disclose a health condition, staff still must respond, but the response may be tempered.
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:* Specify
Race:* Make a selection Black White Asian Native American Multi-Racial Other
Ethnicity:* Make a selection Hispanic Non-Hispanic
Who does child 4 live with?* Make a selection Both Parents Joint Custody Foster Family Other Parent/Guardian Prefer not to answer
Explain:*
Parent/Guardian Name:*
Additional Adult in Household (if applicable): ie, Parent's Boyfriend/Girlfriend
Child 4 - School Information 2023-24 School Year Grade:* Please make a selection K-5th K 1st 2nd 3rd 4th 5th
2023-24 School Year Grade:* Please make a selection K-8th K 1st 2nd 3rd 4th 5th 6th 7th 8th
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 2023-24 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:* If families choose not to disclose a health condition, staff still must respond, but the response may be tempered.
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:* Make a selection Home Cell Work
Secondary Phone: (optional)
Secondary Phone Type: (optional) Make a selection Home Cell Work
Email Address:*
Employer:*
Household Income* Select Income Range 0-$14,999 $15,000-$24,999 $25,000-$34,999 $35,000-$44,999 $45,000-$54,999 $55,000-$64,999 $65,000-$74,999 $75,000-$84,999 $85,000-$94,999 $95,000-$104,999 $105,000+ Unknown Prefer not to answer
Number in Household:*
Other Parent/Guardian (optional) Full Name:
First
Last
Relationship to Member:
Home Address:
Primary Phone:
Primary Phone Type: Make a selection Home Cell Work
Secondary Phone:
Secondary Phone Type: Make a selection 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:* Make a selection Home Cell Work
Contact #2:*
First
Last
Relationship to Member:*
Primary Phone:*
Primary Phone Type:* Make a selection Home Cell Work
Policy and Waiver Information PLEASE READ CAREFULLY
PROGRAM COMMUNICATIONS:
MEDICAL EMERGENCY:
Liability:
PHOTOS/VIDEOS:
AUTHORIZED PICK-UP POLICY:
Or you may choose one of the following: LATE PICK-UP POLICY:
TRAVEL:
PROGRAM PARTICIPATION:
DATA COLLECTION & SHARING:
SCHOOL INFORMATION:
TECHNOLOGY:
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.
