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Big City University Elementary After School Program Application 2021-2022

Please complete the form below. Required fields marked with an asterisk *
What grade will your child be in during the fall?*
Answer Required
What schools does your child attend?*
Answer Required

Home Address:

State*
Answer Required
Student's Sex*
Answer Required
Any custody issues we should be aware of?
Answer Required

Father's Address

State
Answer Required

Mother's Address

State
Answer Required

Legal Guardian's Address

State
Answer Required
Special Services the Student receives. Mark all that apply
Answer Required

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

Medical Information: My student has the following health conditions that may require special care or supports during extended programming hours.
Answer Required
Does your child qualify for free and/or reduced lunch?
Answer Required
Does your child have TNCare Medical Insurance?
Answer Required
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
Where does your student stay at night?
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
Confirmation Email