Multi-School After School Application

21CCLC Multi-School After School Application

Current School Year: 2025-2026
New or returning Student:
Do you have multiple children attending the school selected?
If Yes, How Many?
Choose Your After School Location:
Student Name

First NameMiddle NameLast Name
Student Date of Birth

MonthDayYear
Date
Student Age
Student Grade Level
Student Gender:
Student Demographics (select all they apply)"

Other
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Transportation
Student Medical Information:

(If Yes, please specify.)
Does Student have any non-medical restrictions?

Yes
Does Student have medical insurance?

Yes
Does Student have any allergies?

Yes
Does Student have any serious health issues?

Yes
Does Student take any medications?

Yes
Does Student have any "special healthcare needs"?

Yes
Disclaimer: The CAOWNY is not responsible or liable for any students damaged, lost or stolen items. If a student has special health-care needs, an individual health-care plan form must be completed and submitted to the CAOWNY prior to the student’s start in the CAOWNY program.
Parent Initials
Student Household Information
Member Household Type:
Free/Reduced or Paid Lunch:
Number of adults in the household:
Number of adults in the household:
Language spoken in the household:
Student does not speak English
Yearly Household Income (select a range):
Miltary Household:
If Yes, List Branch:
If Yes:
In case of Emergency

Contact Information: The CAOWNY will only release the student to the parent or legal guardian listed on this form. Individuals authorized to pick up the student may be asked to show a picture identification. The CAOWNY must have a copy of any court orders prohibiting an individual from picking up a student.

Parents are responsible for updating the emergency contact list. We will not release a student to an individual not listed on this form unless written permission is given. NO EXCEPTIONS!
Parent Initials
Primary Contact:
Full Name

First NameMiddle NameLast Name
Relationship to Student:
Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Primary e-mail:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Contact:
Full Name

First NameMiddle NameLast Name
Relationship to Student:
Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Primary e-mail:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3rd Contact:
Full Name

First NameMiddle NameLast Name
Relationship to Student:

Other
Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Primary e-mail:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agreements
Agreement: I, the primary contact, consent to the enrollment of my child in the CAOWNY program and have been advised of the policies regarding the administration of medications, fees, transportation and services provided by CAOWNY, Buffalo Public School and Office of Child and Family Services.
Emergency: In case of accident or injury, I authorize any and all necessary emergency medical, dental, and/or surgical care and hospitalization advised by the physician, surgeon to ensure the proper health and well-being of my child.
Medical: I have provided information regarding my child’s special needs (allergies, diet, disabilities, and/or medical information). I understand this information may be required toassist the medical facility staff in properly caring for my child in the event of an emergency.
Surveys: I give consent for my child to participate in evaluation survey that will assist CAOWNY in measuring the success of the program.
Report Cards: I give consent for the CAOWNY to obtain my child’s report card, Buffalo Public Schools assessment scores during the school year.
Photo Release: I give consent for my child’s photograph to be taken and used in publications, mailings, illustrations, advertising, web content, etc. for marketing during the current school year.
Parent/Legal Guardian Name
Signature
Date
Should be Empty:

Student Medical Information:

Student Household Information

Primary Contact:

2nd Contact:

3rd Contact:

Agreements