YSP After School Program Application 2026

Thank you for your interest in our Young Scholars Program After School Programs. Please read the entire application and fill in all of the required fields.

At this time, we are only enrolling for Young Scholars entering the 1st and 2nd grades.

LifeWise Young Scholars Program

Prescott Benson
Director of Young Scholars Program

pbenson@lifewisestl.org

Parent/Guardian Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Preferred Language

Other

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name

First NameMiddle NameLast Name

Date of birth

Date

Name of school currently attending:

Current Grade Level:

Name of school counselor

Are you in the Free or Reduced Lunch Program?

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)

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.

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.

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).

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.

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.

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

Date

Signature of Parent/Guardian

Date of signature

Date

After School Program Application

PRIMARY PARENT/GUARDIAN/EMERGENCY CONTACT

CHILD INFORMATION

CHILD SCHOOL INFORMATION

RELEASES AND CONSENTS

PICK-UP/EMERGENCY CONTACT INFORMATION

ACKNOWLEDGEMENTS

FINAL SIGNATURE