United Learning After-school Program Application

Student Information

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

Parent/Guardian Information

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

Medical Information

Please provide a copy of your child's insurance card to UCHM prior to the start of the program.
If not, contact Program Director as soon as possible
We collect this information for grant reporting purposes.

Emergency Contacts and Authorized Persons

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.

Consent

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