2025 - 2026 After School Information Form
Please complete this form with as much detail as possible to help our After School Coordinator create the best experience for your child. A completed form is required for every child attending our afterschool program. Afterschool pick up is from Lapham, Nuestro Mundo, and Sandburg elementary schools. Possible pick up is available from Gompers Elementary School.
Name of child
*
First Name
Last Name
Does your child have a nickname they like to be called? What is it?
Age of Child
*
Child's Birthday
Child's Grade Number
Child's School Name
How will your child be getting to the Sensory Zone for afterachool?
Sensory Zone pick up with van
parent drop off
other transportation services
Parent Name Completing This Form.
First Name
Last Name
Parent Email
example@example.com
Parent Phone Number
ex: xxx-xxx-xxxx
What day(s) of the week are you looking for afterschool care for? Select al that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
School's out days
How will you be paying for the After School Program? $35 a day | $150 a week
Invoice me
I will pay at the Sensory Zone
I will be using CLTS (confirm with your CLTS case worked for approval)
Who is your CLTS case worker?
First Name
Last Name
Case workers email
example@example.com
What hobbies or interests does your child have?
*
What diagnoses (if any) does your child have?
*
How does your child communicate? Is there anything the after school program should know about your child's communication? (verbal, written, sign language, talk to text device, AAC device, etc..)
*
Please share with us ways to positively work with your child. What can an after school worker do to ensure your child has a good experience? Does your child have any positive coping skills that they use or like to use?
*
Please share with us ways that the after school worker should not work with or communicate with your child? What does your child NOT like?
*
Does your child require assistance with any of the following:
going up or down stairs
putting on or tying their shoes
opening snacks or drinks (provided by parent, no peanut products please)
transitioning from wheelchair to foam pit, trampoline, crash pad or swing)
bathroom assistance (if clicked, please explain below)
If you clicked bathroom assistance, what assistance would they require?
Does your child have any allergies? If so, to what?
*
Will your child need to take any medication while at the Sensory Zone? All medications will need to be in original bottle with full instructions and kept at the front desk during respite.
Yes
No
What type of medication may your child need to take while at the Sensory Zone? All medications will be administered by lead staff on site that day according to instructions provided.
Which of the following can the staff at the Sensory Zone adminster to your child?
ice pack
tylenol (childrens)
basic medical attention (scratches, bumps, bruises)
cough drop
popsicle for sore throat
Emergency medical attention by training professional (if needed) Guardian will be called if anything happens requiring medical assistance.
What else would you like the after school worker know about your child?
*
Other information not asked for, that you feel is important:
*
Parent #1 Information
First Name
Last Name
Phone Number:
Parent #2 Information
First Name
Last Name
Phone Number:
Emergency Contact Person (non-guardian to contact in case of an Emergency)
*
First Name
Last Name
Emergency Contact Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who IS allowed to pick up the child during pick up?
Who is NOT allowed to pick up the child during pick up?
I allow the Sensory Zone to take pictures of my child engaged in activities for Sensory Zone marketing purposes? (If yes, please sign)
I allow the Sensory Zone to take my child out of the Sensory Zone on a walking/driving field trip if provided all the details prior to the field trip? (If yes, please sign)
Signature of parent/guardian completing this form.
Submit
Should be Empty: