After School Enrollment Form

Registration For ULSA After School Program

********************************Serving Children Ages 5-13********************************
**The Registration/Deposit Fee must be paid when the form is submitted in order to ensure your child's enrollment
Registration & Deposit Fee: ___________ Weekly Tuition Rates:

One Child: $50.00 (NON-REFUNDABLE) One Child: $70.00

Two or More Children: $35.00 Each

***ABC VOUCHERS ACCEPTED

SCHOLARSHIPS: A limited number of Scholarships for Registration, Tuition & Other Fees are available for Residents of Harbison Gardens & Irmo Village. PROOF OF RESIDENCY REQUIRED.

Camp Activities: Daily: Grade level academic enrichment, limited tutorial support, STEAM focus, faith-based instruction.

WEEKLY: outdoor swimming, bowling, sports, skateboarding, field trips,guest speakers.
Check Payable to UCIOCashApp: $ULSAcademyABC Voucher (must submit Voucher Client Connection Card Form with application)
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
What School Does Your Child Attend?
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
STUDENT DEMOGRAPHIC DATA & ENROLLMENT
Student Name:

First NameLast Name
Mother's (Guardian's) Name

First NameLast Name
Father's (Guardian's) Name

First NameLast Name
Student's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's If Different From Student's

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's (Guardian's) Telephone

Area CodePhone Number
Mother's (Guardian's) Work

Area CodePhone Number
Mother's (Guardian's) Cellphone

Area CodePhone Number
Mother's (Guardian's) Email
example@example.com
Father's If Different From Student's

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's (Guardian's) Telephone Number

Area CodePhone Number
Father's (Guardian's) Work Number

Area CodePhone Number
Father's (Guardian's) Cellphone Number

Area CodePhone Number
Father's (Guardian's) Email
example@example.com
STUDENT'S HEALTH INFORMATION & PHYSICIAN REFERENCE FORM
YesNo
Date Received

MonthDayYear
Date
YesNo
Date Received

MonthDayYear
Date
Shot Records And Birth Certificate Documents:

Browse Files

Cancelof
Physician and Emergency Information
Physician's Name

First NameLast Name
Practice Name
Practice Telephone Number

Area CodePhone Number
I give permission to U.L.S.A to make whatever emergency measures are judged necessary for the care and protection of my child while under the supervision of this program. It is understood tht the staff may need to contact the local emergency resources before the parent, child's physician, and/or other adult acting on the parent's behalf. If the local emergency transport deems it necessary to transport my child, it will be to the closest medical facility available.

********I HAVE READ AND UNDERSTAND THE PHYSICIAN AND EMERGENCY INFORMATION PROVIDED ABOVE********
Signature

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Date

MonthDayYear
Date
CHILD'S AUTHORIZED EMERGENCY RELEASE AND PICKUP PERSON
The persons listed below are authorized to pickup my child(ren) if I or his/her other Parent/Guardian is unavailable
Child(ren's) Name

Type a question

Rows	Name of Authorized Person(s)	Relationship to Child	Driver's License #	Home Phone	Cell Phone

***Please Provide Universal Leadership & STEAM Academy With A Copy Of The Driver's License or Legal ID Card With A Photo and Home Address***
Signature

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Date

MonthDayYear
Date
STUDENT'S EDUCATIONAL GOALS AND NEEDS
Student Name:

First NameLast Name
Explain Any Of Your Child's Special Education Needs or Goals
ScienceTechnologyEngineeringMathArtsEnglishSocial StudiesReadingOther
Special One-on-One Classes: (These and Other Special Classes May Be Offered At Various Times As Requested)
DanceMusicKarate
YesNo
If Yes, Give Details:
YesNo
If Yes , Explain Level of Functionality and Independence:
Authorization & Release of Liability Statement
In consideration of the services and facilities provided by Universal Leadership & STEAM Academy, its employees, agents, and officers, I hereby release and forever discharge the aforementioned from any and all liability arising out of my child's participation in this program.
Signature

Clear
Date

MonthDayYear
Date
AUTHORIZATION TO PARTICIPATE IN SPORTS
I do do not give permission for my child to participate in sports activities including swimming on or off campus at ULSA.
Signature

Clear
Date

MonthDayYear
Date
AUTHORIZATION TO PHOTOGRAPH
I do do not give permission to ULSA to take pictures and use the likeness of my child, whether taken on or off campus for promotional use, Social Media or anything other than internal center records.
Signature

Clear
Date

MonthDayYear
Date
AUTHORIZATION TRANSPORTATION
I do do not give ULSA the permission to transport my child from school to their center, to and from the center to our home, everyday for center activities, or on special field trips or in the case of an emergency. Transportation home is limited to children in Harbison Gardens and Irmo Village.
Signature

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Date

MonthDayYear
Date
EMERGENCY MEDICAL AUTHORIZATION
I do do not give ULSA and its staff the permission to get medical help for my child. In emergency cases, I hereby authorize Universal Leadership & STEAM Academy to seek medical treatment for my child. I understand 911 will be called and I, as parent/guardian, will be notified immediately. If my child is to be transported to a medical facility, an adult from ULSA will accompany the child and remain until a parent/guardian or designed person arrives. I understand that I am responsible for all medical cost associated with such emergency.
Signature

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Date

MonthDayYear
Date
MEDICATION AUTHORIZATION
I Type option 1 Type option 2 give ULSA and its staff the permission to administer either prescription or nonprescription medication to my child while attending ULSA, either on or off campus. I have described my child's medical status as requested in this registration packet, including listing all medical conditions and medications that my child takes. I will sign my child's medication on a daily medication log. All medication(s) will be maintained in the original container.
Signature

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Date

MonthDayYear
Date
MEDICATION POLICIES
1. No non-prescription medication will be given at all without doctor's written permission (to include Tylenol, Pandol, and cough syrups).
2. If a prescribe medicine is needed, parents must provide:
  1. Spoon/utensil, with labels and name
  2. Make sure medication is given and picked up from Director or Teacher.
  3. Label all bottels and the child's name and the prescription name, as well as directions.
3. A child will only be given medication that is prescribed to him/her.
If my child must have medication while attending ULSA, I will follow these policies.
Signature

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Date

MonthDayYear
Date
PARENT AUTHORIZATION FORM

*
Date

MonthDayYear
Date
I, blanks (Parent/Guardian), give my child (Child's Name)blank permission to attend the daily After School Sessions at ULSA. I understand that she/he will be transported on a ULSA bus to the center at 220 North Royal Tower Drive, Irmo, SC 29063.
Signature

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Required State Documents

***Print, Sign, and Upload Below***
Required: DSS Form 2900
https://dss.sc.gov/resource-library/forms_brochures/files/2900.pdf

(FILLABLE VERSION LINK FROM DSS SITE. STILL REQUIRED TO PRINT AFTERWARDS AND SIGN)
ABC GROW HEALTHY LEVEL B CHILD CARE DISCIPLINE POLICY
Required: For ABC Voucher Form of Payment Only
Required documents:

Browse Files
(For example: proof of residency and etc.) Cancelof
Parent/Guardian Name Print
Parent Signature

Clear
Date

MonthDayYear
Date
Telephone: (803) 233 - 9299 Cell: (803) 528 - 7995

Website: www.ulsteamaca.org

Email: infoulaa@gmail.com

Address: (P.O. Box 1481) 220 N. Royal Tower Dr., Irmo, SC 29063
Should be Empty:

Registration For ULSA After School Program

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION:

STUDENT DEMOGRAPHIC DATA & ENROLLMENT

STUDENT'S HEALTH INFORMATION & PHYSICIAN REFERENCE FORM

Physician and Emergency Information

CHILD'S AUTHORIZED EMERGENCY RELEASE AND PICKUP PERSON

STUDENT'S EDUCATIONAL GOALS AND NEEDS

Authorization & Release of Liability Statement

AUTHORIZATION TO PARTICIPATE IN SPORTS

AUTHORIZATION TO PHOTOGRAPH

AUTHORIZATION TRANSPORTATION

EMERGENCY MEDICAL AUTHORIZATION

MEDICATION AUTHORIZATION

MEDICATION POLICIES

PARENT AUTHORIZATION FORM

Required State Documents