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 for "Child's First Name:"

Child's Last Name:*

Answer required for "Child's Last Name:"

Student Birthdate:

Answer required for "Student Birthdate:"

What schools does your child attend?*

Answer required for "What schools does your child attend?"

Home Address:

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Home Phone Number:*

Number Required

Cell Phone Number:

Number Required

Ethnicity (Please check all that apply):*

Answer required for "Ethnicity (Please check all that apply):"

Asian

American Indian/Alaskan Native

Black/African American

Hispanic

Pacific Islander/Native Hawaiian

White

Parent's Email Address*

Answer required for "Parent's Email Address"

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

Answer required for "List other children in the family and relationship to the student:"

Custody

Answer required for "Custody"

If yes, please explain what the issues are.

Answer required for "If yes, please explain what the issues are."

Father's Name:

Answer required for "Father's Name:"

Father's Cell phone number:

Number Required

Father's Address

Street Address

Answer required for "Street Address"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Father's employed by:

Answer required for "Father's employed by:"

Father's Work Phone Number:

Number Required

Mother's Name:

Answer required for "Mother's Name:"

Mother's Cell Phone Number:

Number Required

Mother's Address

Street Address

Answer required for "Street Address"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Mother's Cell Phone Number:

Number Required

Mother Employed by:

Answer required for "Mother Employed by:"

Other Custody: Legal Guardian's Name:

Answer required for "Other Custody: Legal Guardian's Name:"

Legal Guardian's Address

Street Address

Answer required for "Street Address"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Legal Guardian's Home Phone Number:

Number Required

Legal Guardian's Cell Phone Number:

Number Required

Legal Guardian's Employed by:

Answer required for "Legal Guardian's Employed by:"

Legal Guardian's Work Number:

Number Required

Legal Guardian's Email:

Answer required for "Legal Guardian's Email:"

Relationship to Student:

Answer required for "Relationship to Student:"

Special Services the Student receives. Mark all that apply

Answer required for "Special Services the Student receives. Mark all that apply"

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 for "First emergency contact name and contact number"

Second Emergency Contact Name and Number*

Answer required for "Second Emergency Contact Name and Number"

Third Emergency Contact Name and Phone Number:*

Answer required for "Third Emergency Contact Name and Phone Number:"

Food Allergy to:

Answer required for "Food Allergy to:"

Other health condition(s):

Answer required for "Other health condition(s):"

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

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

Yes

Does your child have TNCare Medical Insurance?

Answer required for "Does your child have TNCare Medical Insurance?"

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 for "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."

Yes

What is the first language your child learned to speak?

Answer required for "What is the first language your child learned to speak?"

What language does your child speak at home?

Answer required for "What language does your child speak at home?"

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

Answer required for "What language do others speak in your child's home?"

Where does your student stay at night?

Answer required for "Where does your student stay at night?"

Other (Explained)

Answer required for "Other (Explained)"

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 for "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."

Yes

Names of Individuals APPROVED to check out my child:

Answer required for "Names of Individuals APPROVED to check out my child:"

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 for "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:"

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 for "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:"

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 for "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. "

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 for "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."

Please fix the highlighted areas below before submitting.

Big City University Elementary After School Program Application 2024-2025