• Unleashing Potential Registration 2026-27 Ferguson-Florissant

    Unleashing Potential Registration 2026-27 Ferguson-Florissant

  • Unleashing Potential is honored to be able to provide after care in the Ferguson - Florissant school district for the '26-27' school year! This year, care will be offered at an off-site location: Immanuel (221 Church Street, Ferguson,Mo.63135). We will be providing transportation for your child (ren) directly from their schools to our afterschool site.

     After care will be in operation Monday-Friday from 3:40PM-6:30PM. We have done our best to minimize the cost to our families set at $100 per week, per child.


    We ask that you please be mindful that our program is dedicated and reserved for families in need of consistent and daily care. We are not categorized as a drop-in service, therefore once your child has been approved for a slot, he or she will be expected to attend the program daily, and in its entirety for the school year.


    Additionally, please note that you will need to fill out a separate application for each child you are seeking care for.

     

    A separate application is required for each child.

     

     Please designate 15-20 minutes to complete our online application. Please remember to email your supporting documents to tjackson@upstl.org. Without supporting documents, we will be unable to consider your child(ren) for a slot.


    Please allow up to two weeks for processing from the time you’ve received your email confirming your application has been submitted. We will reach out to you with further information regarding your application(s).


    Thank you for your interest in our program, and we look forward to serving your family!
     

  • Please select your location:*

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

  • Student Information

  • Race/Ethnicity*
  • Gender*
  • Does your child identify as LGBTQIA+?*
  • Birth Date*
     . .
    2 digit month, 2 digit day, 4 digit year
  • Grade Level for Fall 2025*
  • County*
  • Lunch Status*

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

  • Does your child have any special needs?*
  • Does your child have an IEP?*
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  • Does your child have a behavior plan?*
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  • Child's Insurance Status*
  • Does your child have a physical or mental condition that limits movements, senses, or activities?*
  • Medical Conditions (select all that apply)*
  • Child's Health Status:*

  • Before admission, additional information or accomodations may be requested for children with disabilities and/or special needs who require additional adult support. Once the information is received, our team will review to determine if the program can accommodate the needs of the child. Please allow at least two weeks after documents are submitted for confirmation.

  • Parent/Guardian Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Employment Status:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Employment Status:*

  • Household Information

  • Total Household Income:*
  • Living Arrangement:*

  • 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:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 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.
  • Format: (000) 000-0000.
  • Is this person authorized to pick up your child?*
  • Format: (000) 000-0000.
  • Is this person authorized to pick up your child?*

  • Child and Youth Intake Assessment Form

    Please complete the following checklist so that Unleashing Potential staff can get to know your child better. When completing the checklist, think about how your child is usually and select the response that best fits your child.
  • My child ...*
    Rows

  • 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*
  • Date of Electronic Signature*
     . .
    2 digit month, 2 digit day, 4 digit year

  • Immunization Records

    Proof of Immunization or exemption from immunization is required before admittance into program.
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  • Does your child have any medical allergies? If Yes, an Allergy Action Plan is required from your child's physician.*
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  • Does your child have asthma? If Yes, an Asthma Action Plan is required from your child's physician.*
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  • 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.

  • Date*
     . .
    2 digit month, 2 digit day, 4 digit year

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

  • I hereby authorize Unleashing Potential, on behalf of its affiliates or anyone authorized by Unleashing Potential, to take photographs, transparencies, film, video and/or audio recording, or any likeness of my child(ren). 

    I understand this information may be used in publications, including electronic publications, audiovisual presentations, promotional literature, advertising, community presentations, and social media. 

    I further authorize Unleashing Potential to use, distribute, publish, or telecast any of the works for the sole purpose of internal and/or external use by Unleashing Potential. I waive any interest in the material. 

    I understand I have the right to request the cessation of recording or filming. I also have the right to rescind consent for use up until a reasonable time before the recording or film is used. 

    I understand that no employee or agent of Unleashing Potential shall have any responisbility to monitor, supervise, or control any aspect of the photography or video recording or any subsequent use of such photographs or videos. 

    I hereby release Unleashing Potential, its agents, and employees from any liability for any and all claims arising out of the taking of photograph(s)/video(s) or any subsequent use thereof.  

  • I give Media - Marketing consent.*

  • Client Rights & Responsibilities

  • Unleashing Potential defines client as the Parents whose child(ren) receives services through our childcare and youth development programs exclusive of young adults ages 18 through 24.

    A copy of Client Rights and Responsibilities can be found on the parent board or at the parent center at your site.

    Unleashing Potential clients have the right to:

    • Be informed of their rights and responsibilities and be provided with enough information to make an informed choice about using the organization and its services

    • Fair and equitable treatment including:
    o The right to receive services in a non-discriminatory manner
    o The consistent enforcement of program rules and expectations
    o The right to receive services that are respectful of, and responsive to, cultural and linguistic differences

    • Accommodations for written and oral communication needs of clients by:
    o Communicating, in writing and orally, in the languages of the major population groups served
    o Providing, or arranging for, bilingual personnel or translators or arranging for the use of communication technology, as needed
    o Providing telephone amplification, sign language services, or other communication methods for deaf or hearing-impaired persons
    o Providing, or arranging for, communication assistance for persons with special needs who have difficulty making their service needs known
    o Considering the person’s literacy level

    • Provide consent prior to receiving services and:
    o Participate in all service decisions; receiving service in a manner that is non-coercive and that protects the person’s right to self-determination
    o Request a review of their care
    o Refuse any service and be informed about the consequences of such refusal, which can include discharge

    • Receive a schedule of any applicable fees and estimated or actual expenses and are informed prior to service delivery about:
    o The amount that will be charged
    o When fees or co-payments are charged, changed, refunded, waived, or reduced
    o The manner and timing of payment
    o The consequences of nonpayment

    • Confidentiality and privacy regarding services rendered unless a legal court order requests such information

    • Be informed on how to lodge complaints or grievances

    • Be safe in the agency’s service environment

    As a client of Unleashing Potential, I recognize my responsibility to:

    • Participate in services specified in my plan including compliance with program rules and regulations

    • Not engage in violent or destructive behavior

    • Honor the confidentiality of others during group activities

    • Provide relevant information as a provision for receiving services and participating in service decisions

  • Agreements, Permissions, and Informed Consent

  • Upon acceptance into the program, I will receive a copy of this facility's policies pertaining to the admissions, care, and discharge of children.*
  • I have been informed that a copy of the Licensing Rules for Group Child Care Homes and Centers is available at this facility for review.*
  • I agree to meet with the provider upon admission to develop a plan for continuing communication regarding my child's development, behavior, and individual needs.*
  • I understand that my child may not be accepted for care and that I will be contacted and must come to pick up my child from the program should they become ill while in care.*
  • 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.*
  • I understand falsifying or omission of information on this enrollment form may be cause for dismissal from the program.*
  • I understand the financial policies and that failure to abide by these policies could result in removal from the program.*
  • I agree to the release of information between the school and after school staff as needed in regards to my child's school work and behavior as needed.*
  • I understand that I may request notice at any time if there are children currently enrolled in or attending the facility for whom an immunization exemption has been filed.*
  • I give permission for my child to participate in surveys while attending the after school program. I understand that participation in surveys is voluntary, will be kept strictly confidential, and will be used to improve service delivery at my child's program and other similar programs at the local and national level.*
  • I give permission for field trip/excursions. I understand that I will be notified in advance of any off-site field trips.*
  • I give permission for the facility to transport my child.*
  • I consent to receive SMS (text) communication from Unleashing Potential's staff pertaining to program schedule changes. This includes notification of program closure due to inclement weather, an unplanned early dismissal and other program closings. When program services are no longer needed, I will chose "Unsubscribe" via SMS (text). A "Help" feature will also be available.*

  • UP Release Form

  • I have requested a slot for my child to participate in Unleashing Potential's School Age programs. As a condition of receiving this benefit, I, the undersigned, do hereby agree to the following:

    I umderstand that signing my child up for participation in this activity is voluntary and can expose my child to situtaions both known and unanticipated risks from normal daily activities such as sports and outdoor play.

    Acknowledging that such risks exist, i hereby release and discharge Unleashing Potential, its officers, agents, and employees from any and all claims or liability for personal injury or property damage my child may suffer while participating in the activity; including, but limited to, any claim arising out of any condition of the premises at which the activity is held or the conduct of any person in conection with the preparation for, supervision of, or conduct of any activity, whether planned or unplanned.

  • Date*
     . .
    2 digit month, 2 digit day, 4 digit year

  • Strengthening Resilient Families

  • If you would like to receive monthly resources (assistance with food/clothing/shelter, housing, parenting resources, etc.) please fill out the information below.*
  • Race/Ethnicity
  • Gender
  • I am ... (Please select all the apply)

  • None of the above information is reported to any authority. This information is collected for funding purposes only and will not impact your ability to access programming.

  • Administrative Use: Please Leave Blank

  • Entry Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Exit Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: