Big City University Elementary After School Program Application 2024-2025

Please complete the form below. Required fields marked with an asterisk *

Child's First Name:*

Answer Required

Child's Last Name:*

Answer Required

Student Birthdate:

Answer Required

What schools does your child attend?*

Answer Required

Home Address:

Street Address*

Answer Required

City*

Answer Required

Zip/Postal

Answer Required

Home Phone Number:*

Number Required

Cell Phone Number:

Number Required

Ethnicity (Please check all that apply):*

Answer Required

Asian

American Indian/Alaskan Native

Black/African American

Hispanic

Pacific Islander/Native Hawaiian

White

Parent's Email Address*

Answer Required

List other children in the family and relationship to the student:*

Answer Required

Custody

Answer Required

If yes, please explain what the issues are.

Answer Required

Father's Name:

Answer Required

Father's Cell phone number:

Number Required

Father's Address

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Father's employed by:

Answer Required

Father's Work Phone Number:

Number Required

Mother's Name:

Answer Required

Mother's Cell Phone Number:

Number Required

Mother's Address

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Mother's Cell Phone Number:

Number Required

Mother Employed by:

Answer Required

Other Custody: Legal Guardian's Name:

Answer Required

Legal Guardian's Address

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Legal Guardian's Home Phone Number:

Number Required

Legal Guardian's Cell Phone Number:

Number Required

Legal Guardian's Employed by:

Answer Required

Legal Guardian's Work Number:

Number Required

Legal Guardian's Email:

Answer Required

Relationship to Student:

Answer Required

Special Services the Student receives. Mark all that apply

Answer Required

Reading

Math

Special Education

Mental Health Supports

IEP

Speech

Behavioral Support

Emergency contacts: You MUST provide three people and their contact numbers

First emergency contact name and contact number*

Answer Required

Second Emergency Contact Name and Number*

Answer Required

Third Emergency Contact Name and Phone Number:*

Answer Required

Food Allergy to:

Answer Required

Other health condition(s):

Answer Required

Does your child qualify for free and/or reduced lunch?

Answer Required

Yes

Does your child have TNCare Medical Insurance?

Answer Required

Yes

Would you be interested in your child receiving social-emotional therapy services through Centerstone while at the after school program? A yes response only allows for Centerstone personal to contact you about this option.

Answer Required

Yes

What is the first language your child learned to speak?

Answer Required

What language does your child speak at home?

Answer Required

What language do others speak in your child's home?

Answer Required

Where does your student stay at night?

Answer Required

Other (Explained)

Answer Required

The information provided above is true and accurate to the best of my knowledge; It is my responsibility to notify the school if my child's medical condition changes and/or they have developed any medical needs that may require attention during after school program hours. Yes, the After School Program may use over-the-counter first aid products as needed for my student as they have no known sensitivity to these items.

Answer Required

Yes

Names of Individuals APPROVED to check out my child:

Answer Required

I have completed the general, medical, and pick-up information. I understand that someone over the age of 18, must present identification every day, and sign out the student at the end of the program night. Typing or signing your name denotes agreement:

Answer Required

I understand the attendance in the after school program is a very important piece of the grant funding. I will make every effort to have my student attend the after school program each Monday-Thursday. Failure to attend can cause your student to lose their spot in the after school program. Typing or signing your name means an agreement:

Answer Required

I understand my child and I may be asked to complete survey information regarding the after school program for evaluation purposes. I agree to participate and complete the survey and have my child participate in such. I also consent to the release for my child's academic and personal information including grades, student conduct, attendance, and standardized test scores. Typing or signing your name is agreement and consent.

Answer Required

I also agree to allow my child to be photographed and allow these photos to be used for marketing or grant reporting. Typing or signing your name is agreement and consent.

Answer Required

Please fix the highlighted areas below before submitting.

Big City University Elementary After School Program Application 2024-2025