Before and Afterschool Care Registration

Young Scholars Learning Center Before/Afterschool Registration Form

2025-2026
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Before and Afterschool Programming Starts September 1st!

Register Today!
Expected Start Date

MonthDayYear
Expected End Date

MonthDayYear
What school do you presently attend?
What days of the week do you need care?
Grade Attending
Pick When
Do you require transportation?
Please note that transportation is an additional fee.
Student Information
First Name
Last Name
Gender
Birth Date

MonthDayYear
Sibling 1

Only Complete if sibling will attend Young Scholars Learning Center
First Name
Last Name
Gender
Birth Date

MonthDayYear
Sibling 2

Only Complete if sibling will attend Young Scholars Learning Center
First Name
Last Name
Gender
Birth Date

MonthDayYear
Parent/Guardian Information 1
Full Name

First NameLast Name
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail
Address - Same As Child
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian Information 2
Full Name

First NameLast Name
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail
Address - Same As Childs
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Other Information
Doctors Name

First NameLast Name
Doctors Phone Number

Area CodePhone Number
Is your child immunized?
Does your child have any allergies?
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?
Does your child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed above?
Waiver and Release of All Claims

WAIVER AND RELEASE OF ALL CLAIMS I hereby acknowledge that the above information provided for the dispensing of medication for my minor child, guardian, ward, or other family member is accurate. I also understand that it is my responsibility to inform the agency if any changes in the dispensing of medication change. In all cases, medication dispensing can only be changed or modified by completing another Medical Information Form. As parent/guardian of the below identified participant, I verify and attest that my child/ward has the knowledge and skills to safely possess, self-administer, and use medication in a camp setting. I also recognize and acknowledge that there are certain risks of physical injury to participants’ possession, self-administration, or use of medication, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward or I may sustain as a result of said possession, self-administration, or use of medication. Such risks include, but are not limited to, failing to properly administer the medication, failing to observe side effects, failing to assess and/or recognize an adverse reaction, failing to assess and/or recognize a medical emergency, and failing to recognize the need to summon emergency medical services. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) as a result of or arising out of the possession, self-administration, or use of medication against Young Scholars Learning Center , including its officials, agents, volunteers and employees; except for claims arising out of the willful and wanton conduct of the Young Scholars Learning Center.
Please list the people authorized to pick up your child.
Please create a 5 digit release code
Only the authorized person listed on the registration form, with the correct release code, will be authorized to pick up the scholar.
Comments
Emergency Contact - Other than Parent/Guardian
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell

Area CodePhone Number
Work

Area CodePhone Number
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list. To ensure a smooth start for all scholars, all program fees must be paid in full before your child begins the program. No exceptions. Any questions or comments please direct them to Meticho O'Neal @ moneal@youngscholarslearningcenter.net or 708-960-2898 *We add a $3.25 surcharge for each invoice payment.
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Young Scholars Learning Center Before/Afterschool Registration Form

Before and Afterschool Programming Starts September 1st!

Student Information

Sibling 1

Sibling 2

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Information

Emergency Contact - Other than Parent/Guardian