• Young Scholars After School Program Application 2022-2023

  • Please read the entire application and fill in all of the required fields. 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.

    Attn: Crystal Fowler at LifeWise StL

    1321 S. 11th Street

    St. Louis, MO 63104

     

    If you have any questions, you may contact Crystal Fowler at

    cfowler@lifewisestl.org

    • CHILD INFORMATION 
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    • CHILD SCHOOL INFORMATION 
    • 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.

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    • CHILD HEALTH INFORMATION 
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    • Please let us know if there are any accommodations that the After School Staff should know about to help support your child. If your child has asthma or food allergies, we must have an inhaler and/or Epipen on site before your child can begin the program.If your child has asthma or food allergies, we must have an inhaler and/or Epipen on site before your child can begin the program

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    • PRIMARY PARENT/GUARDIAN/EMERGENCY CONTACT  
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    • SECOND PARENT/GUARDIAN/EMERGENCY CONTACT 
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    • ADDITIONAL EMERGENCY CONTACT 
    • In the event of an emergency, LifeWise StL will first attempt to contact the primary parent/guardian and then the second parent/guardian (if one is listed). In the event that both parents or guardians cannot be reached, I authorize LifeWise StL to contact our emergency contact. 


      Please list the name of the emergency contact below. If you have already listed two parents or guardians, then this section is optional.

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    • HOUSEHOLD INFORMATION 
    • LifeWise StL receives public funding and is often required to provide basic information about membership households. Please help us continue receiving these funds by providing information about your household. 



    • 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. In the event I cannot be reached in an emergency, I hereby give my permission to employees of LifeWise STL to secure proper medical care for my child as deemed necessary.  This permission extends from minor first-aid treatment to (under a doctor’s orders) hospitalization, injections, anesthesia, surgery, and other medical procedures deemed necessary. 

      I authorize LifeWise StL day care provider or home provider to contact the following:

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    • RELEASES AND CONSENTS 
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    • ACKNOWLEDGEMENTS 
    • A. I HAVE RECEIVED A COPY OF THIS FACILITY’S POLICIES PERTAINING TO THE ADMISSION, CARE AND DISCHARGE OF CHILDREN.

    • 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.

    • C. THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING COMMUNICATION REGARDING MY CHILD’S DEVELOPMENT, BEHAVIOR, AND INDIVIDUAL NEEDS.

    • D. WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE ACCEPTED FOR CARE OR REMAIN IN CARE.

    • 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.

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    • PICK-UP/EMERGENCY CONTACT INFORMATION 

    • PLEASE INLUDE YOURSELF ON THIS FORM. ALL PERSONS LISTED MUST BE 18 YEARS OF AGE OR OLDER.

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    • FINAL SIGNATURE  
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