United Learning After-school Program Application

Student Information

Student Name *

First

Last

Sessions Your Child Will Attend: *

Child's Preferred Name

Child's Date of Birth *

Current School

Current Grade

Child Gender

Child Ethnicity

We collect this information for grant reporting purposes. Selection is optional if you wish not to identify.

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Parent/Guardian Phone Number (Cell) *

Parent/Guardian Phone Number (Home)

Parent/Guardian Phone Number (Work)

Parent/Guardian E-mail Address *

Parent/Guardian Place of Employment

2nd Parent/Guardian Name

First

Last

2nd Parent/Guardian Phone Number (Cell)

2nd Parent/Guardian Phone Number (Home)

2nd Parent/Guardian Phone Number (Work)

2nd Parent/Guardian E-mail Address

2nd Parent/Guardian Place of Employment

Family Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please list any areas of academic performance where child experiences challenges

Please list any areas of academic performance where child excels

Is your child in an Individual Education Program (IEP)?

Yes
No

We encourage you to provide a copy of the student's IEP upon enrollment. This information helps us provide the best learning environment possible.

How do you hope that your child will benefit from this program?

Medical Information

Medical Insurance Carrier/Policy Number

Please provide a copy of your child's insurance card to UCHM prior to the start of the program.

Preferred Hospital

Allergies: Please provide detailed information regarding any allergies your child has and indicate severity and treatment options.

Please provide any information regarding any medical conditions or diagnoses.

Does the allergy require use of epi-pen?

Yes
No

Is your child current on all immunizations/vaccinations?

If not, contact Program Director as soon as possible

Please list any behavioral issues, learning challenges, or any other information that will assist us in ensuring your child has a positive experience in our program.

Is there any other information about your child that you think would be helpful for us to know?

Emergency Contacts and Authorized Persons

1. Emergency Contact Name, Relationship, Phone Number *

2. Emergency Contact Name, Relationship, Phone Number *

In addition to yourself and the emergency contacts listed above, please list any other person(s) authorized to pick up your child from the program. Your child will only be released to the persons on this form.

List name, phone number, and relationship to child

Financial Information

The fee for the United Learning program is $25/week. Please select a payment preference below.

Checkboxes

I do not need financial assistance and I will pay the weekly fee by Monday of each week
I do not need financial assistance and I will pay the weekly fee on a monthly basis on the 15th of each month
I would like to apply for financial assistance

Does your child receive free/reduced lunch?

Yes
No

We collect this information for grant reporting purposes.

Annual Gross Household Income

We collect this information for grant reporting purposes.

Consent

Medical Consent Signature *

In the event that my child becomes ill or sustains any injury while attending the youth program at UCHM and/or while on an authorized and chaperoned activity sponsored by UCHM (on or off UCHM property), I, the undersigned, give my permission to the adult leader(s) to administer first aid and/or CPR and to select a physician and/or hospital for my child’s care, releasing her/him from liability for their actions. UCHM Youth Program Staff are CPR/First Aid Certified. Also, I give the emergency care personnel, physicians, and/or hospital my permission to examine, treat, and provide medical, dental, or surgical diagnoses for my child. They may also x-ray, administer medication or anesthesia as deemed necessary. Further I give EMS and any other emergency transportation service my permission to transport my child. I understand that this consent and release will apply to all emergency situations present and future.

Field Trip Consent Signature

I also give permission for my child to go on any UCHM sanctioned field trip. I understand that a copy of this form, after signed, is as valid as the original. This consent/release form shall remain in effect until written revocation to UCHM or until 18 months after date signed.

Photo Release Signature

I give permission for my child’s picture to be taken and used in UCHM’s newsletter, social media, or other publicity materials. UCHM will not give children’s names or any identifying information within any agency publication. Pictures will be used to share the work of UCHM with the community, donors, and supporters.

Email *

Please enter your e-mail so we can send a you confirmation that we have received your application.

2022-23 United Learning After-school Program Application

Student Information

Parent/Guardian Information

Medical Information

Emergency Contacts and Authorized Persons

Financial Information

Consent

Address