Registration Ferguson-Florissant 2024-25

Unleashing Potential Registration 2024-25 Ferguson-Florissant
Unleashing Potential provides after care in the Ferguson - Florissant school district at Berkeley, Griffith, Robinwood, and Combs through a 21st Century Learning Center grant. This funding allows us to offer the program at no cost to the families at these locations. Our program is not a drop-in service but is dedicated to families in need of consistent and daily care. Once your child has been approved for a slot, it is expected that your child attends the program daily.

A separate application is required for each child.

The application takes approximately 15 minutes to complete online. Supporting documents can be emailed to ljacobs@upstl.org. You will receive an email upon submission. Please allow up to one week for processing and notification of a slot.
Please select the school you are applying for.

BerkeleyGriffithRobinwoodCombs
At this time, we can only accommodate after care services. We will notify all parents if we are able to offer morning care.

Authorization for Emergency Care

I understand that I will be notified at once in case of an emergency and I will make arrangements for medical care of my child with the physician or hospital of my choice. Unleashing Potential does not transport but will contact EMS personnel for transporting to a medical facility if necessary. Unleashing Potential is not responsible for the costs associated with medical care or transportation. If I cannot be reached to make necessary arrangements, or in a critical emergency requiring immediate medical care, I authorize Unleashing Potential to contact the following:
Physician or Clinic Name: *
Physician or Clinic Phone Number*
Please enter a valid phone number.
Preferred Hospital*
Preferred Hospital Phone Number*
Please enter a valid phone number.
Signature*

Clear
Emergency Contacts/Designated Escorts

Persons authorized to take your child from the program other than the parent/guardian. They should be reliable and able to pick up and/or make emergency decisions regarding your child in case of emergency.
Emergency Contact Name #1 (someone other than a parent)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Relationship to Student:*
Is this person authorized to pick up your child?*

YesNo
Emergency Contact Name #2 (someone other than a parent)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Relationship to Student:*
Is this person authorized to pick up your child?*

YesNo

For question (1) "Listens to and follows directions of those in charge," if you responded not usually, what types of reminders are helpful?
For questions (5) "is able to take care of own physical needs," if you responded not usually, what does your child need assistance with?
In new situations, my child tends to...*
When your child gets frustrated or upset, what does your child find calming or soothing? What helps your child get back on track?*
What type of additional support services does your child receive during the school day?*
Please explain any special needs your child may have: (allergies, dietary needs, physical concerns, self-help assistance or communication concerns).*
How does your child receive praise?*
Please share any additional comments you would like for us to know about your child.

Medication Authorization

A record of administration will be retained in child's record
Missouri Department of Health and Senior Services

Section for Child Care Regulation

Medication Authorization

MO 580-1875 (6-14)

Prescription medication shall be in the original container and labeled with the child's name, Instructions (including times and amounts for dosages), and the physician's name. All non-prescription medication shall be in the original container and labeled by the parent(s) with the child's name and instructions for administration, including times and amounts for dosages. A separate form is needed for each medication. This form is valid only for the dates indicated below
My child takes medication that they might need during programming*

YesNo
I authorize child care personnel to administer the following medication(s) to my child: *
Please use proper name of medication(s)
Possible side effects of medication(s):
Signature*

Clear
Date of Electronic Signature*

MonthDayYear
Date
Immunization Records

Proof of Immunization or exemption from immunization is required before admittance into program.
Upload Immunization Record(s) Here:*

Cancelof
Upload Child Medical Examination Report (provided from physician)? This is a required document for participation: *

Cancelof
Does your child have any allergies? If Yes, an Allergy Action Plan is required from your child's physician.*

YesNo
Upload Allergy Action Plan:*

Cancelof
Does your child have asthma? If Yes, an Asthma Action Plan is required from your child's physician.*

YesNo
Upload Asthma Action Plan:*

Cancelof
Health Care Policies
Unleashing Potential Healthcare Policies

The state of Missouri requires (9CSR 30-62.192) that your child MUST have a health exam or complete a Parent's Health Statement Form for School Age Children and immunizations must be up to date prior to the first day of attendance.

If your child shows signs of general discomfort or seems unwell, their temperature will be taken.

There will be NO EXECEPTION for children who exhibit the following symptoms:

1.) Fever over one hundred degrees (100F) by mouth or ninety-nine degrees (99F) under the arm
2.) Diarrhea - more than one (1) abnormally loose stool
3.) Severe coughing - high pitched croupy sound, whooping sounds
4.) Yellowish skin or eyes
5.) Pink eye - tears, redness of eyelining, swelling, drainage, pus
6.) Vomiting more than once
7.) Headache or stiff neck
8.) Severe itching of body or scalp
9.) Any type of communicable disease
10.) An infected skin patch(es) - crusty, bright yellow, dry, or gummy areas of the skin

The child must be picked up immediately once notified. They will be kept isolated from the other children until the parent/guardian arrives. Be assured that our staff will be attentive to them.

When a child goes home with a communicable disease such as pink eye, lice, rashes, colds with discolored mucus, yellow discoloration of eyes or skin, impetigo, or ringworm, they must have a doctor's statement to return.
Signature*

Clear
Date of Electronic Signature*

MonthDayYear
Date

	Most of the time	Some of the time	Not usually
1. Listens and follows instructions
2. Can make their own decisions without peer input
3. Gets along with peers
4. Gets along with adults
5. Is able to take care of their own physical needs
6. Is able to independently choose and participate in activities
7. Has skills to negotiate needs/wants when they differ from the needs of the group
8. Requests help from adults when needed
9. Works/plays with a variety of children
10. Prefers small group activities
11. Prefers large group activities

Unleashing Potential Registration 2024-25 Ferguson-Florissant

Student Information

Health Report for School-Age Child. Child's Health History and Current Health Problems.

Parent/Guardian Information

Household Information

Authorization for Emergency Care

Emergency Contacts/Designated Escorts

Child and Youth Intake Assessment Form

Medication Authorization

Immunization Records

Health Care Policies

Media-Marketing Consent and Release of Liability for Photographing and/or Video Recording

Client Rights & Responsibilities

Agreements, Permissions, and Informed Consent

UP Release Form

Strengthening Resilient Families

Administrative Use: Do not fill out.