DWCA Youth Center for Excellence

DYNAMIC WORKS

YOUTH CENTER FOR EXCELLENCE

REGISTRATION FORM

Thank you for your interest in our after school program! Here are some helpful FAQs:

Dates: The program starts in September and continues Monday - Friday throughout the school year.

Program hours: 2:30pm - 6:30pm

Registration Fee: $50 (one time fee)

Weekly Pricing: $285/week

Pricing + Transportation: $325/week

Transportation: Dynamic Works will provide transportation from school to our program each day. If you would like your student to also receive transportation home, there is an additional fee (listed above). Parents/guardians are responsible for picking up their student from the program by 6:30pm if their student is not being transported home by Dynamic Works.
Student's Name*
Nickname (if applicable)
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Race

White/CaucasianBlack/African-AmericanHispanicAsianAmerican IndianMullti-racialOther
Home Address*
Current School*
Grade*
Will your student be receiving transportation home, provided by Dynamic Works?*

YesNo
Photo & Media Release*

Yes, I give permission for my student's images to be used in videos or photos that may be used in program materials, promotional materials, social media, etc.No, my student's image may not be used in Dynamic Works images or videos.
PARENT(S)/GUARDIAN(S)
Guardian 1*
Home Phone*
Email Address*
example@example.com
Home Address*
Place Employed
Business Phone
Guardian 2
Home Phone
Email Address
example@example.com
Home Address
Place Employed
Business Phone
Agency Having Legal Custody of Child (if applicable)
Agency Address
Agency Representative's Email Address (ex. Social Worker, etc.)
example@example.com
Phone
EMERGENCY INFORMATION
Please list two emergency contacts in the event that a parent/legal gaurdian cannot be reached
Person 1 - Authorized To Pick Up Child*
Phone*
Address
Person 2 - Authorized To Pick Up Child*
Phone*
Address
Person(s) NOT Authorized To Pick Up Child (if applicable)
Appropriate paperwork such as custody papers shall be submitted to the center if a parent is not allowed to pick up the student. NOTE: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center must be included, upon the request of such noncustodial parent, as an emergency contact for events occurring during school or day care activities. 032-05-252/11 (06/05)
Child's Physician
Health Insurance Carrier
Policy Number
Does the student have any medical diagnoses or conditions (including mental health diagnoses)? If so, please list.
Does the student have any known allergies or food intolerances? If so, please list.
Is the student currently on any medications? If so, please list.
Supporting Documents: If applicable, attach any ISFP, IEP, 504 plan, or psychological evaluations. Please note, all documents are kept confidential per Dynamic Works policies.

Cancelof
I certify that all information on this form is complete and true.*

Yes, I certify.
Signature*

Clear
Should be Empty:

PARENT(S)/GUARDIAN(S)

EMERGENCY INFORMATION