After School Application 2024-2025

Young Scholars After School Program Application
Please read the entire application and fill in all of the required fields. 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.

Attn: Amanda Boyd

1321 S. 11th Street

St. Louis, MO 63104

If you have any questions, you may contact Amanda Boyd at

aboyd@lifewisestl.org

CHILD INFORMATION
Name*

First NameMiddle InitialLast Name
Preferred name/nickname:
Address*

Street Address

Apartment or Unit Number

CityState

Zip Code
Gender*
Age*
Date of Birth*

MonthDayYear
Race/Ethnicity:*
Language spoken at home:*
Who does the child live with?*
Has your child attended After School before?*

YESNO
Child Shirt Size*

XSSMLXL
Child Shirt Size Continued*

Youth sizesAdult sizes

CHILD SCHOOL INFORMATION
Name of school currently attending:*
Grade level:*
Are you in the Free or Reduced Lunch Program?*

YESNO
Has your child ever participated in Special Education services or had an IEP? 504 Plan? A behavior plan?*

NOYES
If yes, please explain any accommodations/modifications/services that the scholar receives.
Does your child have a behavior plan?*

NOYES
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

PRIMARY PARENT/GUARDIAN/EMERGENCY CONTACT
Parent/Guardian Name*

First NameLast Name
Age*
Gender*
Race/Ethnicity:*
Date of Birth*

MonthDayYear
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
Email*
Employment Status*
If you are currently employed, what is the name of your employer?
If you are currently in school, where do you attend school?
Highest level of education completed:*

Less than High SchoolHigh School diploma/GEDProfessional/Technical School (1-2 years)Associate’s DegreeBachelor's DegreeMaster’s/Doctorate
Are you currently enrolled in LifeWise StL services?*

YESNO
How did you hear about LifeWise StL?

SECOND PARENT/GUARDIAN/EMERGENCY CONTACT
Second Parent/Guardian/ or Emergency Contact Name

First NameLast Name
Age
Gender
Race/Ethnicity:
Date of Birth

MonthDayYear
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
Email
Employment Status
If you are currently employed, what is the name of your employer?
If you are currently in school, where do you attend school?

ADDITIONAL EMERGENCY CONTACT
In the event of an emergency, LifeWise StL 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.

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 Emergency Contact

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to child
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
example@example.com

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 more
Total household size*
Total number in household under 18 *
Does your family have a working vehicle?*

YESNO

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. In the event I cannot be reached in an emergency, I hereby give my permission to employees of LifeWise STL to secure proper medical care for my child as deemed necessary. This permission extends from minor first-aid treatment to (under a doctor’s orders) hospitalization, injections, anesthesia, surgery, and other medical procedures deemed necessary.

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

ACKNOWLEDGEMENTS
A. I HAVE RECEIVED A COPY OF THIS FACILITY’S POLICIES PERTAINING TO THE ADMISSION, CARE AND DISCHARGE OF CHILDREN. THERE IS A QR CODE BELOW, PLEASE SCAN IT WITH YOUR PHONE'S CAMERA TO VIEW AN ELECTRONIC COPY OF OUR AFTER SCHOOL PROGRAM PARENT HANDBOOK.
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

PICK-UP/EMERGENCY CONTACT INFORMATION
Transportation: After programming, my child will be picked-up, may be transported home in the LifeWise StL van, or is allowed to walk home. Please check all that apply.*

I will pick-up my childI give permission for my child to walk homeI need transportation for my childOther
*Please note that transportation by LifeWise StL is not guaranteed, and is only offered on a limited as-needed basis for families without other alternatives. We currently assist with transportation for the following zip codes: 63102, 63103, 63104, 63106, 63107, 63111, 63116, 63118, and 63139.
PLEASE INLUDE YOURSELF ON THIS FORM. ALL PERSONS LISTED MUST BE 18 YEARS OF AGE OR OLDER.
Authorized Person #1 (Parent/Guardian)*

First NameLast NameRelationship to child
Authorized Person #1 Address*

Street Address

Apartment or unit number

CityState

Postal / Zip Code
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Authorized Person #2

First NameLast NameRelationship to child
Authorized Person #2 Address

Street Address

Apartment or unit number

CityState

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Authorized Person #3

First NameLast NameRelationship to child
Authorized Person #3 Address

Street Address

Apartment or unit number

CityState

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number

FINAL SIGNATURE
Child's Information*

First NameLast Name
Signature of Parent/Guardian*

Clear
Date of signature

MonthDayYear
Should be Empty:

Young Scholars After School Program Application