The S.I.S. Program Interest Form
Please complete the following form to receive more information regarding The S.I.S. Program Enrollment Process.
Participant's Name
First Name
Last Name
Participant's Age
Child’s Date of Birth
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Is the Child Insured via Medicaid? (If No, Private Pay Options are Available.)
Yes
No
Does your Child Exhibit Behavioral or Mental Health Concerns? (Here at The S.I.S. program we provide Mental Health Support in addition to a Focus on Dance and The Performing Arts. Applicants without an underlying challenge will not be processed for Full Enrollment.)
Can your Schedule Accommodate the following Days of Programming: Mon-Tues-Wed 4-6:30 PM
Yes
2 out of 3 Days (Yes)
No
How did you hear about The S.I.S. Program?
Please Select
School
Friends/Family
Online
Other
Student is interested in the following: (Select all that Apply.)
Dance
Art
Acting
Content Creating
Music & Performance Ability
The S.I.S. Program is housed within The boys & Girls Club (Homer Hannah). After-School Meals are Provided on a daily basis (or if your Student plans to pack a Snack.) Does Your Child currently have a Membership to The Boys & Girls Club?
Yes
No
Applicants would be responsible for their own Transportation, to & from Programming. Is this a commitment your family can Accommodate?
Yes
No
Would you be Interested In More Information regarding Summer Programming? M-Fri 10-12:30 PM
Yes
No
Would you like to Subscribe to Our Monthly Newsletter to Stay up to Date with Upcoming Events?
Please Select
Yes
No
Please Provide Additional Questions/Concerns Regarding your Family’s Needs or Information you’d like to share. We Thank You in Advance!
Submit
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