Afterschool information form
To help our staff create the best possible experience for your child, please take a few moments to complete this form with as much detail as you can. A completed form is required for every child attending our afterschool program. Afterschool rates will be billed at the beginning of the month and due within 2 weeks. The fee is $35 per day or $150 for the week.
Name of child
*
First Name
Last Name
Does your child have a nickname they like to be called? What is it?
Grade of child
*
Child's birthdate
Has your child attended our afterschool program before?
Yes
NO
What school will your child need pick up from?
Lapham Elementary
Marquette Elementary
Emerson Elementary
Nuestro Mundo Elementary
Sandburg Elementary
My child will be dropped off by taxi or other transportation at the Sensory Zone
What days of the week will your child be attending the afterschool program? Click all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
Please share with us ways to positively work with your child. What can a staff do to ensure your child has a good experience? Does your child have any positive coping skills that they use or like to use?
Does your child require assistance with any of the following:
going up or down stairs
putting on or tying their shoes
opening snacks or drinks (provided by parent, no peanut products please)
transitioning from wheelchair to foam pit, trampoline, crash pad or swing)
bathroom assistance (if clicked, please explain below)
If you clicked bathroom assistance, what assistance would they require?
Does your child have any allergies? If so, to what?
*
Will your child need to take any medication while at the Sensory Zone? All medications will need to be in original bottle with full instructions and kept at the front desk during respite.
Yes
No
What type of medication may your child need to take while at the Sensory Zone? All medications will be administered by lead staff on site that day according to instructions provided.
Which of the following can the staff at the Sensory Zone adminster to your child?
ice pack
tylenol (childrens)
basic medical attention (scratches, bumps, bruises)
cough drop
popsicle for sore throat
Emergency medical attention by training professional (if needed) Guardian will be called if anything happens requiring medical assistance.
What hobbies or interests does your child have?
*
What else would you like the staff to know about your child?
*
Other infomation not asked for that you feel is important:
*
Parent #1 Information
First Name
Last Name
Phone Number:
Email
example@example.com
Parent #2 Information
First Name
Last Name
Phone Number:
Email
example@example.com
Emergency Contact person (non guardian to contact in case of an Emergency)
*
First Name
Last Name
Emergency Contact phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who IS allowed to pick up the child?
Who is NOT allowed to pick up the child?
I allow the Sensory Zone to take pictures of my child engaged in activities for Sensory Zone marketing purposes? (If yes, please sign)
I allow the Sensory Zone to transport my child from school and to any small field trips offered during their time with the afterschool program.
I understand that the afterschool program at the Sensory Zone is designed for children who are able to participate in small group activities.
Submit
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