After School Child Registration Form

  • TRANSPORTATION AT CAPACITY

    REQUEST ARE NOT AVAILABLE

  • Instructions

    Please complete the after school child registration application below. All information –and supporting documentation—must be received to be accepted and registered. You may save your information as you go and return as many times as needed. If you are registering multiple children, please complete an application for each child. If you are registering a teen, there are essay questions as a part of the application. We accept students on a rolling basis throughout the school year. Please contact our office by phone at 404-627-8050 if you have specific questions regarding this application or our after school programs.

  • After-School Child Registration Form

    2024-2025 School Year

  • Program Fees & Needs-based Scholarship

    The after school program is offered at ZERO cost to families who meet income eligibility requirements and at a modest cost to families who exceed the income threshold. At the end of the application you will have the opportunity to download the household income packet to determine your scholarship eligibility. Completed household income packets and supporting information may be sent to our Program Manager Danielle Erwin at derwin@eastatlantakids.org.

  • Child Information

  • Parent/Guardian Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contacts

    Emergency contacts are required and must not be the primary parent/guardian.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Teen Essay Questions

  • Teen Program Essay Questions

    Instructions: Please respond thoughtfully to each question below in 250 words maximum. You will be selected to participate based on the quality of your response. It would be best to seek advice from a guidance counselor, teacher, or parent for help before submitting your essay. Students who plagiarize or who do not write their own responses will not be accepted.
  • 0/250
  • 0/250

  • Screening Certification Parent Form

  • Privacy Statement for Youth Participants and Families Regarding Authorization for Release of Information

  • The East Atlanta Kids Club has an ongoing program to track the impact that our program may have on our child participants’ attendance, performance and behavior in school, as well as their behavior at Kids Club and in the community at large. In order to generate this data, we will request the following information on an annual or bi-annual basis. This information may be generated in written or oral form from you, your child, and the school system.

    • School records, including grades, behavior, attendance, and standardized test scores will be requested from the school system. The purpose will be to review performance and changes in performance level resulting from their participation in Kids Club.
    • Nutritional, fitness, and other program surveys that allow Kids Club to evaluate
      and improve youth programming and determine the impact of our programs on the child’s behavior.
    • Parental and child surveys reviewing attitudes and behavioral changes that you and your child may have seen as a result of the child participating in Kids Club.

    We will keep all records that we collect confidential. The data may be used or disclosed for research or statistical purposes. All reporting that results from this data will be completely anonymous, and will not include the names or any personally identifiable information about any child. Compliance with this request is voluntary and may be terminated at any time.

    Your cooperation in our data collection program will be most appreciated.

  • Parent Permission Form

  • I permit my child to participate in the East Atlanta Kids Club Programming (hereafter “the Program”). I have read and understand the rules, regulations, and structure of the Program. I have met with an EAKC staff member to discuss my child’s participation. I understand that some of the people who serve as tutors and mentors in the Program are a mix of paid professionals and adult volunteers from the community who have been carefully screened by the organization. The meetings between my child and their tutors/mentors will take place both at the site of the Program (Brownwood Park Recreation Center) and off-site.

    On some occasions, staff and/or volunteers will transport my child to and from the Program site and my child’s residence, as well as to and from field trip venues. I understand that all contacts between volunteers and my child are scheduled, monitored by EAKC staff, and evaluated. Any additional contacts between the adult mentors and my child/children must be scheduled in advance and be approved by me.

    I understand that East Atlanta Kids Club is a free Program offered at no charge to children and their parents based on income eligibility guidelines provided by the Program. The Program does not require cash or in-kind donations or payments for youth whose families meet income eligibility guidelines provided by the Program.

    I assume all risks and hazards incidental to the conduct of the Program activities. In the event of any injury or loss to my child, I hereby release, absolve, indemnify and hold harmless the East Atlanta Kids Club, the organizers of the activities, sponsors, supervisors, and volunteers, any and all of them.

  • Authorization for Release of Educational Information

  • I personally and hereby consent and authorize the release of educational information concerning my child (aforementioned in this application) to the EAST ATLANTA KIDS CLUB. This information includes: any and all records of the above-named child’s school attendance, grades, standardized test scores, conduct and disciplinary actions, for the past three school years, or for the time periods requested by EAST ATLANTA KIDS CLUB. Please provide such information to Ryan Downey, Executive Director, EAST ATLANTA KIDS CLUB, or their designees, at 602 Brownwood Avenue, SE, Atlanta, GA 30316. Phone: 404-627-8050.Please cooperate with EAST ATLANTA KIDS CLUB in securing the information requested.

    This release is for all purposes and has an indefinite duration, unless otherwise limited herein. All other prior releases are hereby revoked unless noted as an exception herein. You are instructed that the release of this information pursuant to this authorization is not intended to alter, waive or destroy the confidential nature of information retained by you, nor to relieve you from continuing duties to safeguard such information. Photocopies of this release shall be deemed to be the original and the same consideration shall be given the photocopy as if the original was presented. Please be sure that any photocopies provided are readable copies.

    This release may be revoked by me in writing. If you have any questions concerning this release, please contact EAST ATLANTA KIDS CLUB at the number and address above.

  • Acknowledgment of Program Licensure Status

  • Medical History

    Please mark N/A for any fields that are not applicable
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Health Information Form

  • Medications

  • Please indicate if your child is currently taking any medication (or will be) during program. Please list below:

  • Medical Waiver and Release Form

  • This health history is correct and complete as far as I know. The completed health information form may be printed/ photocopied for trips out of camp. I, the parent/guardian of the child named below, hereby give my permission for his/her participation in the East Atlanta Kids Club After-School Mentoring and/or Summer Camp program (the “Program”).

    On behalf of my child, I assume all risks and hazards incidental to the conduct of the Program. In consideration of my child being permitted to participate in the Program, I hereby waive, release, discharge, indemnify, and hold harmless the East Atlanta Kids Club, its officers, directors, members, employees, and agents, as well as all organizers, sponsors, partners, supervisors, volunteers, and participants involved in the presentation of the Program, and each of their officers, directors, members, employees, and agents, from all liability for any damage, loss, or injury to person or property which may be sustained as a result of my child’s participation in the Program, even if such damage, loss, or injury is the result of negligence, in whole or in part, of any of these entities.

    Further, I hereby give my permission to have my child treated on the scene and/or to take my child to a doctor or hospital in case of any injury at the Program.

    I hereby acknowledge that I have carefully read and understand this Waiver and Release agreement and that I am freely and voluntarily signing it.

  • Photo and Media Release Form

  • Approved Guardian List

    I give permission for the following person(s) excluding myself to pick up my child from East Atlanta Kids Club. I affirm that the person(s) listed are 18 years or older and can provide a valid photo ID.
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