2024 CDF Freedom Schools Program Application

2024 LifeWise StL CDF Freedom Schools Program Application
Thank you for your interest in LifeWise StL CDF Freedom School. Please read the entire application and fill in all of the required fields (marked with a red asterisk). Incomplete applications will not be accepted. You may upload the required documents (most recent report card, most recent physical exam, immunization records) directly to this form using the orange "upload a file" buttons. Documents can also be dropped off or mailed directly to LifeWise StL.

The Freedom Schools program has a history of impacting scholars by helping them improve their reading skills and prevent summer learning loss. For the program to be effective, scholars need to have good attendance and fully participate in the program. This year LifeWise will be charging a $30 deposit, per family, to hold your scholar's place in the program. Please know that upon completing the program and good attendance, you will receive a full refund of your deposit. Good attendance will be considered for any scholar who attends 25 days or more of the program. Please know that documented attendance in summer school will not count against your scholar's Freedom School attendance. The $30 (per family) refundable deposit is due with your application. Please mail or drop-off a check for $30 made out to LifeWise StL. If you have any questions or concerns please do not hesitate to contact your local site coordinator.

This year, there will be a one-time non-refundable $100 transportation fee (per family) for those children being transported each day by the LifeWise StL van service. Transportation is subject to availability. The $100 transportation fee will be due at the time that transportation availability is confirmed.

If you are applying for more than one child, please fill out this entire form and at the end of the form, there will be a link to complete a shorter form for each additional child you are applying for. This means that the parent information, emergency contact, household information, releases and consents, and acknowledgements sections will only have to be completed once per family.

If you have any questions, you may contact:

For grades K-8

Rasheed Ajayi

abdulrasheedajayi@lifewisestl.org

314-627-1241

For grades 9-12

Tawnya Johnson

tjohnson@lifewisestl.org

314-260-6384

LifeWise StL

1321 S. 11th Street

St. Louis, MO 63104

PRIMARY PARENT/GUARDIAN #1
Parent/Guardian Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*
Race/Ethnicity:*
Address *

Street Address

Apartment or Unit Number

CityState

Postal / Zip Code
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Email*
Are you currently employed?*
If yes, what is the name of your employer/employers?
Are you currently in school?*

YESNO
If yes, where do you attend school?
Are you currently enrolled in LifeWise StL services?*

YESNO

SECOND PARENT/GUARDIAN #2
Second Parent/Guardian Name

First NameLast Name
Date of Birth

MonthDayYear
Gender
Race/Ethnicity:
Relationship to child
Address (If different from that of parent/guardian #1)

Street Address

Apartment or Unit Number

CityState

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Email
Are you currently employed?
If yes, what is the name of your employer?
Are you currently in school?

YESNO
If yes, where do you attend school?
Are you currently enrolled in LifeWise StL services?

YESNO

ADDITIONAL EMERGENCY CONTACT
In the event of an emergency, LifeWise StL Staff will first attempt to contact the primary parent/guardian and then the second parent/guardian (if one is listed). In the event that both parents or guardians cannot be reached, I authorize LifeWise StL to contact our emergency contact. Emergency contacts must be 18 or older.

Please list the name of the emergency contact below. If you have already listed two parents or guardians, then this section is optional.
Name of Additional Emergency Contact

First NameLast Name
Relationship to child
Address (If different from that of child)

Street Address

Apartment or Unit Number

CityState

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number

PICK-UP INFORMATION
Please list anyone (in addition to the primary parents/guardians) who you authorize to pick-up your child. All persons listed must be 18 years of age or older.
Authorized Person #1

First NameLast NameRelationship to child
Person #1 Cell Phone Number

Area CodePhone Number
Person #1 Home Phone Number

Area CodePhone Number
Authorized Person #2

First NameLast NameRelationship to child
Person #2 Cell Phone Number

Area CodePhone Number
Person #2 Home Phone Number

Area CodePhone Number
Authorized Person #3

First NameLast NameRelationship to child
Person #3 Cell Phone Number

Area CodePhone Number
Person #3 Home Phone Number

Area CodePhone Number

HOUSEHOLD INFORMATION
LifeWise StL receives public funding and is often required to provide basic information about membership households. Please help us continue receiving these funds by providing information about your household.
Family Annual Income (Please select one)*

$0-$9,999$10,000-$14,999$15,000-$19,999$20,000-$29,999$30,000-$49,999$50,000-$99,999$100,000 or Greater
Primary language spoken at home:*
Total household size*
Total number in household under 18 *
Do you have a working vehicle?*

YesNo

ACKNOWLEDGEMENTS
A. I HAVE RECEIVED A COPY OF THIS FACILITY’S POLICIES PERTAINING TO THE ADMISSION, CARE AND DISCHARGE OF CHILDREN.
Parent/ Legal Guardian Initials
Please type your initials in the box
B. I HAVE BEEN INFORMED THAT A COPY OF THE LICENSING RULES FOR CHILD CARE HOMES OR THE LICENSING RULES FOR GROUP CHILD CARE HOMES AND CENTERS IS AVAILABLE AT THIS FACILITY FOR REVIEW.
Parent/ Legal Guardian Initials
Please type your initials in the box
C. THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING COMMUNICATION REGARDING MY CHILD’S DEVELOPMENT, BEHAVIOR, AND INDIVIDUAL NEEDS.
Parent/ Legal Guardian Initials
Please type your initials in the box
D. WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE ACCEPTED FOR CARE OR REMAIN IN CARE.
Parent/ Legal Guardian Initials
Please type your initials in the box
E. I UNDERSTAND THAT, BEFORE THE FIRST DAY OF ATTENDANCE BY MY CHILD, I WILL PROVIDE PROOF OF COMPLETED AGE-APPROPRIATE IMMUNIZATIONS OR EXEMPTION FROM IMMUNIZATIONS.
Parent/ Legal Guardian Initials
Please type your initials in the box
F. I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENT OR ANY TIME THERE AFTER WHETHER THERE ARE CHILDREN CURRENTLY ENROLLED IN OR ATTENDING THE FACILITY FOR WHOM AN IMMUNIZATION EXEMPTION HAS BEEN FILED.*

YESNO
Parent/ Legal Guardian Initials
Please type your initials in the box
Signature of Parent/ Legal Guardian*

Clear
Date of signature*

MonthDayYear

CHILD INFORMATION
Name*

First NameMiddle InitialLast Name
Preferred name/nickname:
Has your child participated in the CDF Freedom Schools summer program before?*

YESNO
If yes, how many years has your child participated in the CDF Freedom Schools summer program?
Address (If different from primary parent)

Street Address

Apartment or Unit Number

CityState

Postal / Zip Code
Date of Birth*

MonthDayYear
Gender*
Race/Ethnicity:*
Child Shirt Size*

XSSMLXL
Child Shirt Size Continued*

Youth sizesAdult sizes

CHILD SCHOOL INFORMATION
Name of school currently attending:*
Grade level that your child is starting in the fall: *
Are you in the Free or Reduced Lunch Program?*

YESNO
Has your child ever participated in Special Education or had a 504 plan? IEP?*

YESNO
Does your child have a behavior plan?*

YESNO
What are some strategies that LifeWise StL can use to best support your child's learning throughout the program? (ex: positive reinforcement, small groups)
LifeWise StL does offer therapeutic/behavioral support through individual therapy and social emotional skills groups. If interested in the possibility of individual therapy for your child/the child for whom you are serving as legal guardian, please see Authorizations-Observation/Referral below to opt in.
PLEASE INCLUDE A COPY OF YOUR CHILD'S MOST RECENT REPORT CARD. IF YOU HAVE AN ELECTRONIC COPY, YOU MAY UPLOAD IT USING THE BUTTON BELOW.

Upload a File

Cancelof

AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE OF AN EMERGENCY WITH MY CHILD, AND I WILL MAKE ARRANGEMENTS FOR THE MEDICAL CARE OF MY CHILD WITH THE PHYSICIAN OR HOSPITAL OF MY CHOICE.

IF I CANNOT BE REACHED TO MAKE NECESSARY ARRANGEMENTS, OR IN A CRITICAL EMERGENCY REQUIRING MEDICAL CARE, I AUTHORIZE LifeWise StL DAY CARE PROVIDER OR HOME PROVIDER TO CONTACT THE FOLLOWING:
Name of Child's Primary Physician or Clinic *
Physician or Clinic phone number

Area CodePhone Number
Preferred Hospital*
Preferred Hospital phone number

Area CodePhone Number
Signature of Parent/ Legal Guardian*

Clear
Date of signature*

MonthDayYear

TRANSPORTATION INFORMATION
Transportation: After programming, my child will be picked-up by an authorized person listed above, may be transported home in the LifeWise StL van, or is allowed to walk home. Please check all that apply. *Please note that transportation by LifeWise StL is not guaranteed, and is only offered on a limited basis for families without other alternatives.*

Pick-UpVanWalk HomeOther

FREEDOM SCHOOL SITE
LifeWise StL operates multiple Freedom School locations during the summer. Please select your preferred location. We will do our best, but cannot guarantee your preference. Spots are reserved on a first come, first serve basis.*

LifeWise StL (K-5th grade) 1321 S. 11th Street, St. Louis, MO 63104Maplewood UMC (K-5th grade)7409 Flora Ave., St. Louis, MO 63143Beloved UMC (6th-8th grade)3115 Park Ave., St. Louis, MO 63104Webster Hills UMC (6th-8th grade) 698 W. Lockwood Ave., Webster Groves, MO 63119LifeWise Academy (9th-12th grade) 1025 Park Ave., St. Louis, MO 63104
**THE FOLLOWING SECTION IS FOR THE MAPLEWOOD UMC LOCATION ONLY**

Maplewood United Methodist Church intends to offer child care from 3pm to 5:30pm after Freedom School. These after school child care services are separate from, and not provided by, LifeWise StL. Any agreement you have related to after care following the end of Freedom School is solely with Maplewood United Methodist Church and not the responsibility of LifeWise StL.
Parent/Guardian Initials:
If you would like for your child to participate in aftercare, please complete the following release of information so that the information from this application can be shared with the staff at Maplewood UMC. If your child will not be attending at the Maplewood UMC location, you may leave the following section blank.
RELEASE OF INFORMATION

I authorize LifeWise StL to release information regarding my child (indicated below) for service coordination.
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Information to be released from LifeWise StL to:

Maplewood UMC

7409 Flora Ave.

St. Louis, MO 63143

This release will expire one year from today's date. I understand that this release is valid when I sign it and that I may withdraw my consent to release at any time in writing by updating this form.
Signature of Parent/Guardian

Clear
Date of signature

MonthDayYear

FINAL SIGNATURE
I understand that student, health, parent/guardian, emergency contact and household information will be updated annually, and that my signature grants the above signed permissions for the duration of my child’s participation in the LifeWise StL CDF Freedom Schools Program and that I may withdraw my consent at any time by submitting a request in writing.
Signature of Parent/Guardian*

Clear
Date of signature*

MonthDayYear
If you would like to apply for another child in your family, please visit the following link to complete only the child-specific sections of this form. Make sure that you click "submit" on this form before adding an additional child.

https://form.jotform.com/240517320763148
Should be Empty:

2024 LifeWise StL CDF Freedom Schools Program Application