Before & After Care Application

Youth Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Date Of Birth

Mother’s Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Mobile Phone

Email Address

Place of Employment

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Father’s Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Mobile Phone

Email Address

Place of Employment

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

Emergency Contact Name

Phone

Emergency Contact Name

Phone

Emergency Contact Name

Phone

Name Of Child’s Physician

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Special Disabilities (If Any)

Allergies(Including Medication Reaction)

Medical or Dietary Information

Additional Information On Special NeedsOf Youth:

Health Insurance or Medical Assistance:

Policy Number

Youth May Walk/Trips

Youth May Go Swimming/Wadding

Youth Can Be Transported

Youth Name

Grade

Youth Room #

School Youth Attends:

Will youth be picked up/walk home:

What is your payment method:Option 1Option 2Option 3

Type 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 2

I understand youth are suppose to be picked up from the program by 5:50 pm:Option 1Option 2

I understand snack will be provided or youth can bring their own:Option 1Option 2

Are there any allergies:

What are your child strengths & weakness in regards to homework?

Upload Youth Birth Certificate

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Upload Youth Physical

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Upload Parent Identification

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Upload Youth Photo

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