CDF Freedom Schools Program Application 2022

2022 LifeWise StL CDF Freedom Schools Program Application
Please read the entire application and fill in all of the required fields (marked with a red asterisk). Incomplete applications will not be accepted. You may upload the required documents (most recent report card, most recent physical exam, immunization records) directly to this form using the orange "upload a file" buttons. Documents can also be dropped off or mailed directly to LifeWise StL.

For grades K-8

Emma Patterson

1321 S. 11th Street

St. Louis, MO 63104

For grades 9-12

Tawnya Johnson

1025 Park Ave

St. Louis, MO 63104

If you have any questions, you may contact:

Emma Patterson, emmapatterson@lifewisestl.org, 314-627-1241

or

Tawnya Johnson, tjohnson@lifewisestl.org, 314-260-6384

CHILD INFORMATION
Name *

First Name Middle Initial Last Name
Preferred name/nickname:
Has your child participated in the CDF Freedom Schools summer program before? *

YES NO
If yes, how many years has your child participated in the CDF Freedom Schools summer program?
Address *

Street Address

Apartment or Unit Number

City State

Postal / Zip Code
Date of Birth *

Month Day Year
Age *
Gender *
Race/Ethnicity: *
Language spoken at home: *
Child Shirt Size *

XS S M L XL
Child Shirt Size Continued *

Youth sizes Adult sizes

SCHOOL HISTORY
Name of school currently attending: *
Grade Level: *
Are you in the Free or Reduced Lunch Program? *

YES NO
Has your child ever participated in Special Education or had a 504 plan? IEP? *

YES NO
Does your child have a behavior plan? *

YES NO
What are some strategies that LifeWise StL can use to best support your child's learning throughout the program? (ex: positive reinforcement, small groups)
LifeWise StL does offer therapeutic/behavioral support through individual therapy and social emotional skills groups. If interested in the possibility of individual therapy for your child/the child for whom you are serving as legal guardian, please see Authorizations-Observation/Referral below to opt in.
PLEASE INCLUDE A COPY OF YOUR CHILD'S MOST RECENT REPORT CARD. IF YOU HAVE AN ELECTRONIC COPY, YOU MAY UPLOAD IT USING THE BUTTON BELOW.

Upload a File

Cancel of

HEAD OF HOUSEHOLD: PARENT/GUARDIAN INFORMATION
Parent/Guardian Name *

First Name Last Name
Date of Birth *

Month Day Year
Age *
Gender *
Race/Ethnicity *
Address *

Street Address

Apartment or Unit Number

City State

Postal / Zip Code
Cell Phone Number *

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Email *
Are you currently employed? *

YES NO
If yes, what is the name of your employer?
What is your current work schedule?
Address of Employer (if applicable)

Street Address

Street Address Line 2

City State

Postal / Zip Code
Are you currently in school? *

YES NO
If yes, where do you attend school?
What is your current school schedule?
Are you currently enrolled in LifeWise StL services? *

YES NO

SECOND PARENT/GUARDIAN/EMERGENCY CONTACT
Second Parent/Guardian Name

First Name Last Name
Date of Birth

Month Day Year
Age
Gender
Race/Ethnicity:
Relationship to child
Address

Street Address

Apartment or Unit Number

City State

Postal / Zip Code
Cell Phone Number

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Email
Are you currently employed?

YES NO
If yes, what is the name of your employer?
What is your current work schedule?
Address of Employer (if applicable)

Street Address

Street Address Line 2

City State

Postal / Zip Code
Are you currently in school?

YES NO
If yes, where do you attend school?
What is your current school schedule?

AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE OF AN EMERGENCY WITH MY CHILD, AND I WILL MAKE ARRANGEMENTS FOR THE MEDICAL CARE OF MY CHILD WITH THE PHYSICIAN OR HOSPITAL OF MY CHOICE.

IF I CANNOT BE REACHED TO MAKE NECESSARY ARRANGEMENTS, OR IN A CRITICAL EMERGENCY REQUIRING MEDICAL CARE, I AUTHORIZE LifeWise StL DAY CARE PROVIDER OR HOME PROVIDER TO CONTACT THE FOLLOWING:
Name of Child's Primary Physician or Clinic *
Physician or Clinic phone number

Area Code Phone Number
Preferred Hospital *
Preferred Hospital phone number

Area Code Phone Number
Signature of Parent/ Legal Guardian *

Clear
Date of signature *

Month Day Year

ACKNOWLEDGEMENTS
A. I HAVE RECEIVED A COPY OF THIS FACILITY’S POLICIES PERTAINING TO THE ADMISSION, CARE AND DISCHARGE OF CHILDREN.
Parent/ Legal Guardian Initials
Please type your initials in the box
B. I HAVE BEEN INFORMED THAT A COPY OF THE LICENSING RULES FOR CHILD CARE HOMES OR THE LICENSING RULES FOR GROUP CHILD CARE HOMES AND CENTERS IS AVAILABLE AT THIS FACILITY FOR REVIEW.
Parent/ Legal Guardian Initials
Please type your initials in the box
C. THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING COMMUNICATION REGARDING MY CHILD’S DEVELOPMENT, BEHAVIOR, AND INDIVIDUAL NEEDS.
Parent/ Legal Guardian Initials
Please type your initials in the box
D. WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE ACCEPTED FOR CARE OR REMAIN IN CARE.
Parent/ Legal Guardian Initials
Please type your initials in the box
E. I UNDERSTAND THAT, BEFORE THE FIRST DAY OF ATTENDANCE BY MY CHILD, I WILL PROVIDE PROOF OF COMPLETED AGE-APPROPRIATE IMMUNIZATIONS OR EXEMPTION FROM IMMUNIZATIONS.
Parent/ Legal Guardian Initials
Please type your initials in the box
F. I GIVE PERMISSION FOR FIELD TRIPS/EXCURSIONS ( I UNDERSTAND THAT I WILL BE NOTIFIED IN ADVANCE WHEN THEY ARE PLANNED). *

YES NO
Parent/ Legal Guardian Initials
Please type your initials in the box
G. I GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD. *

YES NO
Parent/ Legal Guardian Initials
Please type your initials in the box
H. I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENT OR ANY TIME THERE AFTER WHETHER THERE ARE CHILDREN CURRENTLY ENROLLED IN OR ATTENDING THE FACILITY FOR WHOM AN IMMUNIZATION EXEMPTION HAS BEEN FILED. *

YES NO
Parent/ Legal Guardian Initials
Please type your initials in the box
Signature of Parent/ Legal Guardian *

Clear
Date of signature *

Month Day Year
Child's Information *

First Name Last Name Age

PICK-UP/EMERGENCY CONTACT INFORMATION
PLEASE INLUDE YOURSELF ON THIS FORM. ALL PERSONS LISTED MUST BE 18 YEARS OF AGE OR OLDER.
Authorized Person #1 (Parent) *

First Name Last Name Relationship to child
Authorized Person #1 Address *

Street Address

Apartment or unit number

City State

Postal / Zip Code
Cell Phone Number *

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Authorized Person #2

First Name Last Name Relationship to child
Authorized Person #2 Address

Street Address

Apartment or unit number

City State

Postal / Zip Code
Cell Phone Number

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Authorized Person #3

First Name Last Name Relationship to child
Authorized Person #3 Address

Street Address

Apartment or unit number

City State

Postal / Zip Code
Cell Phone Number

Area Code Phone Number
Home Phone Number

Area Code Phone Number

FREEDOM SCHOOL SITE
LifeWise StL operates multiple Freedom School locations during the summer. If your child is completing K-4th grade, please select your preferred location. We will do our best but cannot guarantee your preference.

LifeWise StL: 1321 S. 11th Street, 63104 Connection UMC: 6701 Virginia Ave., 63111

FINAL SIGNATURE
Signature of Parent/Guardian *

Clear
Date of signature

Month Day Year
Should be Empty:

2022 LifeWise StL CDF Freedom Schools Program Application