Before & After Care Application Youth Name *Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeDate Of BirthMother’s NameStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeMobile PhoneEmail AddressPlace of Employment Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodePhoneFather’s NameStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeMobile PhoneEmail AddressPlace of Employment Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabwePhoneEmergency Contact NamePhoneEmergency Contact NamePhoneEmergency Contact NamePhoneName Of Child’s Physician Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodePhoneSpecial Disabilities (If Any)Allergies(Including Medication Reaction)Medical or Dietary Information Additional Information On Special NeedsOf Youth:Health Insurance or Medical Assistance:Policy NumberYouth May Walk/TripsOption 1Option 2Youth May Go Swimming/WaddingOption 1Option 2Youth Can Be TransportedOption 1Option 2Youth NameGradeYouth Room #School Youth Attends:Will youth be picked up/walk home:What is your payment method:Option 1Option 2Option 3Type of Care ($10 off for each additional child will be applied weekly, if you have more then one child.)One ChildTwo ChildrenFinancially unable to pay I understand payments are to be made the in the beginning of each week or bi-weekly:Option 1Option 2I understand youth are suppose to be picked up from the program by 5:50 pm:Option 1Option 2I understand snack will be provided or youth can bring their own:Option 1Option 2Are there any allergies:What are your child strengths & weakness in regards to homework?Upload Youth Birth Certificate Choose FileNo file chosenDelete uploaded fileUpload Youth PhysicalChoose FileNo file chosenDelete uploaded fileUpload Parent Identification Choose FileNo file chosenDelete uploaded fileUpload Youth PhotoChoose FileNo file chosenDelete uploaded fileSend Message