Afterschool Application - Home Beneath Our Feet

Afterschool Program Application

You can view, download or print our Afterschool Program Application below:

PDF Version here:

Applicant Information

Students Name: *

First

Middle

Last

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Phone: *

Date of Birth: *

School: *

Grade: *

Male or Female: *

Nickname:

Applicant Information

Name of Person applying for Child: *

Relationship to Child: *

Employer: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone: *

Email *

In case of an emergency, notify: (List contact information for hours during Day Care -for example work address and phone if at work)

Parent/Guardian

DOB

Address

Address Line 1

Address Line 2

City

State

Zip Code

Day Phone

Cell Phone

Parent/Guardian

DOB

Address

Address Line 1

Address Line 2

City

State

Zip Code

Day Phone

Cell Phone

Other

DOB

Address

Address Line 1

Address Line 2

City

State

Zip Code

Day Phone

Cell Phone

Physician or Medical Svc

Address

Address Line 1

Address Line 2

City

State

Zip Code

Names of individuals authorized to pick up child who are NOT listed above:

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Health Information

The following information must be filled in by the parent/guardian. The intent of this information is to provide staff the background to provide appropriate care. Provide complete information so that we can be aware of your child's needs.

Allergies / Describe reaction and management of the reaction

• Medications (e.g., penicillin)

Reaction

• Food (e.g., eggs, dairy)

Reaction

• Other (e.g., insect stings, hay fever)

Reaction

Insurance

Is participant covered by family medical/hospital insurance? *

Carrier/plan name

Name of insured

Relationship to child

insurance ID #

Group #

Carrier Address

Any activities that child cannot participate in or needs one-on-one assistance? *

If yes, please explain

Any additional information about the child's behavior and physical, emotional or mental health the staff should be aware of?

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