After School Program Application 2025

After School Program Application
Thank you for your interest in our After School Programs. Please read the entire application and fill in all of the required fields. You may upload required documents directly to this form using the boxes labeled "Browse Files." Documents can also be dropped off or mailed directly to LifeWise StL. Please see below for contact information for our program directors.

At this time, we are only enrolling for LifeWise Academy (Grades 9-12)

LifeWise Academy

(Grades 9-12)

Darrius Harris, M.Ed.
Director of LifeWise Academy

1025 Park Avenue

St. Louis, MO 63104

dharris@lifewisestl.org
PRIMARY PARENT/GUARDIAN/EMERGENCY CONTACT
Parent/Guardian Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Preferred Language*

EnglishSpanishSomaliOther
CHILD INFORMATION
Name*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Date
CHILD SCHOOL INFORMATION
Name of school currently attending:*
Current Grade Level:*
Name of school counselor*
Are you in the Free or Reduced Lunch Program?*

YESNO
If your child has an IEP, 504 Plan, or Behavior Plan, what are some strategies that LifeWise StL can use to best support your child's learning throughout the program? (ex: positive reinforcement, small groups)
IF YOU HAVE A COPY OF THE CHILD'S IEP, 504 PLAN, OR BEHAVIOR PLAN, PLEASE UPLOAD IT USING THE BUTTONS BELOW (YOU CAN UPLOAD MULTIPLE DOCUMENTS HERE)

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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.

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CHILD HEALTH INFORMATION
CURRENT PHYSICAL AND IMMUNIZATION RECORDS ARE REQUIRED. IF YOU HAVE ELECTRONIC COPIES, YOU MAY UPLOAD THEM USING THE BUTTONS BELOW.

Recent Physical Exam
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Immunization Records
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RELEASES AND CONSENTS
CONSENT 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.*

YESNO
TRANSPORTATION RELEASE: I hereby give permission to LifeWise StL to transport my minor child in a motor vehicle driven by an authorized LifeWise StL staff member. This includes being transported from school to LifeWise StL and from LifeWise StL to home. I understand my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver. I understand participation in the identified event is not a requirement or a right for my child’s participation in the program, and can be revoked based on poor behavior.*

YESNO
FIELD TRIPS CONSENT: Youth development program activities involve transportation to and from the destination. Some field trips may require a separate nominal fee. I grant permission for my child to be transported to field trips during academic year activities. I also acknowledge that I may be required to provide additional fees for specific field trips. (I understand that I will be notified in advance when they are planned/scheduled).*

YESNO
LEAVING LIFEWISE STL PREMISES CONSENT: I hereby give permission to my minor child (age 12 or older) to leave LifeWise StL premises unattended. I understand that if my minor child decides to leave the LifeWise StL premises, LifeWise StL will not be held responsible for their whereabouts.*

YESNO
BUS TICKET CONSENT: As an after-school program that serves students across the St. Louis Metro area, LifeWise Academy can provide Metro bus passes to students to get to and from LifeWise Academy. I hereby give LifeWise Academy permission to give my minor child St. Louis Metro Bus passes to get to and/or from LifeWise Academy and/or events sponsored by LifeWise Academy. I understand that only LifeWise Academy scholars may use these bus passes, and they may only use them to get to and/or from LifeWise Academy and/or events sponsored by LifeWise Academy.*

YESNO
Can your child swim?*

YES, swims very wellYES, but only knows basic swimmingNO
PICK-UP/EMERGENCY CONTACT INFORMATION
Does your family have a working vehicle?*

YESNO
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 Pick-Up Person #1 (Parent/Guardian)*

First NameLast Name
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick-Up Person #2

First NameLast Name
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick-Up Person #3

First NameLast Name
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
ACKNOWLEDGEMENTS
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
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
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
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
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
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.
Parent/Legal Guardian Initials*
Please type your initials in the box
Signature of Parent/Legal Guardian*
Date of signature*

MonthDayYear
Date
FINAL SIGNATURE
Signature of Parent/Guardian*
Date of signature*

MonthDayYear
Date
REQUIRED DOCUMENTS FOR SCHOLAR STIPEND ELIGIBILITY
THE FOLLOWING DOCUMENTS ARE REQUIRED FOR SCHOLAR STIPEND ELIGIBILITY. IF YOU HAVE ELECTRONIC COPIES OF THESE DOCUMENTS, YOU MAY UPLOAD THEM USING THE LINKS BELOW
- Picture ID (student ID, state-issued ID)
- Social Security Card OR Birth Certificate (to be photo-copied at LifeWise Academy)
- Federal W-4
- Missouri W-4
Picture ID

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Social Security Card OR Birth Certificate

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Federal W-4

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Missouri W-4

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Should be Empty:

After School Program Application

PRIMARY PARENT/GUARDIAN/EMERGENCY CONTACT

CHILD INFORMATION

CHILD SCHOOL INFORMATION

CHILD HEALTH INFORMATION

RELEASES AND CONSENTS

PICK-UP/EMERGENCY CONTACT INFORMATION

ACKNOWLEDGEMENTS

FINAL SIGNATURE

REQUIRED DOCUMENTS FOR SCHOLAR STIPEND ELIGIBILITY