University City Registration 2025-2026

School Age Services Registration Form 2025-26 School Year
Thank you for your interest in Unleashing Potential's School Age Services. We provide After Care programs during out-of-school times. Please allow up to two weeks for the review and confirmation of your child's admission into the program. Submission of an application does not guarantee placement. If there is a fee associated with your program, a separate link will be sent directly to you. The application will take approximately 15 minutes to complete and requires that immunizations, IEP, and Behavior Plans be uploaded.

A SEPARATE APPLICATION IS REQUIRED FOR EACH CHILD.

Our programs operate Monday-Friday. Registration is for the entire week to hold a slot for your child. Even if your child will not attend daily, you are requesting that we hold a slot for your child. We are not a drop-in program. Fees are charged per month and not per day. Please notify the Site Manager of extended absences. When funding is available, we are able to waive fees and offer discounts or scholarships. Funding sources are not consistent and often limited. When funding is not available, a fee will be assessed.

All invoicing for programs will be completed through Wonderschool. Once accepted, an invite will be emailed allowing access to your child(ren)'s account. All payments must be made through the portal.

We are offering After Care programs at the following schools

Barbara C. Jordan - After Care 3:30-6:00pm

Flynn Park- After Care 3:30-6:00pm

Jackson Park - After Care 3:30-6:00pm

Pershing - After Care 3:30-6:00pm

Unfortunatley, we are unable to offer morning care at this time. If there is a change in programming availability we will notify families.
Please select a location:

Barbara C. JordanFlynn ParkJackson ParkPershing
Please indicate if there are regular days that your child will not be in attendance.

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).*
For an allergy, please only include things that require immediate medical intervention (i.e. life saving medication)
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 medical 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

School Age Services Registration Form 2025-26 School Year

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: Please Leave Blank