After School Application 2022-2023

CHILD SCHOOL INFORMATION
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 services or had an IEP? 504 Plan? A behavior plan? *

NO YES
If yes, please explain any accommodations/modifications/services that the scholar receives.
Does your child have a behavior plan? *

NO YES
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

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.
Name of Emergency Contact

First Name Last Name
Date of Birth

Month Day Year
Date
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
example@example.com

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:
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 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

PICK-UP/EMERGENCY CONTACT INFORMATION
Transportation: After programming, my child will be picked-up, may be transported home in the LifeWise StL van, or is allowed to walk home. Please check all that apply. *

Pick-Up Van Walk home
PLEASE INLUDE YOURSELF ON THIS FORM. ALL PERSONS LISTED MUST BE 18 YEARS OF AGE OR OLDER.
Authorized Person #1 (Parent/Guardian) *

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

Young Scholars After School Program Application 2022-2023