After-School Program Application

The United Crescent Hill Ministries United Learning Youth After-school Program is a partnership between youth, their families, their schools, and our staff and volunteers. Together, we encourage students’ mental, physical and emotional well-being and growth throughout the school year. The overarching goal of the United Learning program is to help students achieve academic success and develop positive behaviors and relationships with peers and adults.

The United Learning program offers a safe and supportive environment where a child can work on his/her homework and school assignments with supervision and assistance. In addition, we provide opportunities for youth to expand their skills and knowledge, build confidence, and develop positive social and emotional learning skills.

During the school year, UCHM uses peer tutors to work with the youth in addition to staff and adult volunteers. Each peer tutor is at least three grades ahead of any child the tutor helps. The peer tutors are excellent students who have been interviewed by our staff and approved to volunteer in our program for a designated time period. UCHM also utilizes adult volunteers to assist students with homework help as well as provide assistance with general program activities. All volunteers are screened during a background check and provided training.

Our expectations for participation in the United Learning program require that together we will:

Set specific goals and action steps for each school year. These will be signed by all of us as our pledge to be respectful of each other and steadfast in our commitment to work to address the needs of the youth in the program.
Review the student’s progress reports so we can all be aware of how he/she is doing and make any needed changes in the plans to help the student to be successful.
Share with each other any information available from school, self-disclosure, observation, or other resources that would enable a better understanding of the student’s capabilities, progress and needs.
Follow the expectations, set by UCHM staff and students, at all times. Together, we will develop these expectations the first week of the program.

UCHM’s United Learning program serves Kindergarten – Eighth Grade (K-8) children and operates from 3:00pm – 6:00pm on afternoons when school is in session. For the 2019-2020 school year, the United Learning program will begin on Monday, August 19, 2019 and end on Thursday, May 28, 2020. The program will follow the Jefferson County Public School schedule for closings and holidays. UCHM’s program is not a “drop-in” program; children must be pre-registered to participate. Please contact Katie Litanga at 893-0346. You can also email Katie at klitanga@uchmlouky.org.

The fee for the United Learning program is $25/week per child. However, we will never turn a family away from this program for inability to pay, and we offer financial aid to those who request assistance. To apply for financial assistance, please indicate that you would like to apply in your application.

2019-2020 UCHM After-School Program Application

Student Information

Student Name *

First

Last

Child's Preferred Name

Child's Date of Birth *

Current School

Current Grade

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 *

Street Address/City/Zip

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)?

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?

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

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.

Financial Assistance

I wish to apply for financial assistance

The Program Director will contact you to complete the application for financial asssitance.

Email *

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

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