Youth Exposure Afterschool Program 2024-2025

YE Electronic Afterschool Registration Form 2024-2025

Youth Exposure's Afterschool Program begins Monday 9/23/24 -12/6/24 2pm - 6pm Orientation 9/12 & 9/13 3pm - 5pm. 12 Slots Available
Participant's Name*

First NameMiddle NameLast Name
Gender*

MaleFemale
Birth Date*

MonthDayYear
Age Group*

12 - 1415 - 19
What school does the participant attend ?*
What grade is the participant in ?*
Does the participant have an IEP ?*

YESNO
If yes, does the participant have IEP support ?*

YESNO
If the participant does not have IEP support, are you interested in IEP support?*

YESNO
Does the participant have a Behavioral 504 plan?*

YESNO
Does the participant need a Tutor?*

YES, THE PARTICIPANT NEEDS A TUTORMATH TUTOR NEEDEDELA TUTOR NEEDEDNO, THE PARTICIPANT DOES NOT NEED A TUTOR
What is the participants reading grade level ?*
What is the participants math grade level ?*
Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant E-mail*
example@example.com
Mobile Number*
Phone Number*
Beauty Workshops will cover the following

Financial LiteracyWig-MakingEsthetic Workshops 16yrs +( lashes, brows, skincare)Branding and Marketing a Beauty Business
Parent / Guardian Contact Name*

First NameLast Name
Parent / Guardian Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relation to Participant *
Mother/Father, Grandmother/Father, etc
Parent's Contact Number *
Please enter a valid phone number.
Parent's Work Number*
Emergency Contact Name *

First NameLast Name
Emergency Contact Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact Relation to student *
Mother/Father, Grandmother/Father, etc
Phone Number*
Please enter a valid phone number.
Work Number*
Health Questionnaire

(What are your child health concerns ?)
Is the participant currently under medical care ?*

YESNO
Does the participant have allergies ?*

YES (if so list below)NO
Select all ALLERGY TYPES that applies to the participant and explain below*

EnvironmentFoodMedicationsN/AOther
Explain all Allergies below *
If "Other" Explain.
Does the participant have medical conditions please check all that applies:*

AsthmaSeizuresMigraine/HeadachesHigh/Low Blood PressureN/AOther
Does the participant have mental health conditions? please check all that applies.*

DepressionAnxietyBi-PolarPersonality DisorderMood DisorderN/AOther
Does the participant receive Mental Health Services? please check all that applies.*

YesNoN/A
Does the participant want a Mental Health Service referral ?*

YesNoN/A
Please Explain all medical and mental health conditions in this area. ( this area can not be left blank )*
Has the participant been arrested before?*

YesNoN/A
Does the participant have a court order?*

YesNoN/A
Please Explain all arrest and court orders in this area. List dates of arrest, nature of charge . Upload court documents ( this area can not be left blank )*
Is the Participate under foster care, in residential living, or under some form of care regulated by the State*

YesNoN/A
Do you have a case manager you must report to?*

YesNoN/A
Please Explain ( Answering Yes will not hold you back from being approved. Please provide name and contact of case manager(s)This area can’t not be left blank )*
I grant Youth Exposure, Inc. and its affiliates permission to use my / my child’s likeness/ image for films, videos, and /or audiotape recordings, slides, and photographs. I understand that Youth Exposure, Inc. and its affiliates may use my likeness on its website(s) or in other official printed promotional material(s) / media without further consideration. I acknowledge that I will make no monetary reward or claim against Youth Exposure, Inc. and its affiliates for using my / my child's image(s).*

I Grant PermissionI do not Grant Permission
What is the name of Primary Care physician ? *
Primary care physician Address ?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
(Upload participants application, school, Id, last report card, IEP/504 plan, parents / guardian ID, court related documents )*

You must upload all required documents to be considered for approval.
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YE Electronic Afterschool Registration Form 2024-2025

Health Questionnaire