YEAT UP Membership Enrollment Form

YEAT UP Membership Enrollment Form

Complete this form to request membership and program enrollment for your student—submission is reviewed by YEAT UP and does not guarantee placement.
Student Information
Student legal name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Student home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current grade
School or homeschool status

Other
Requested start date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student School Name
Pronouns
Age eligibility notice
Parent/Guardian Information
Parent/Guardian 1 Full Name

First NameMiddle NameLast Name
Relationship to Student
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Same as Student Address
Preferred Communication Method
Parent/Guardian 2 Full Name

First NameMiddle NameLast Name
Relationship to Student
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Who should receive primary enrollment and payment communication?
Does the student live with both listed guardians?
Family, custody, or communication instructions
Program Selection
Which program(s) are you requesting?
Is your family interested in limited scholarship or community-access information?
If you selected “Not sure / Help me choose,” please share the student’s interests, preferred schedule, and goals.
Student Interests, Learning and Participation
What does your student enjoy, care about, or want to learn?
Areas of interest

Other
Learning preferences and supports

Other
How independently can the student participate in a small-group activity?
Can the student independently communicate basic needs or use an established communication method?
Is the student independently restroom-capable?
YEAT UP staff do not provide toileting or personal-care assistance. A team member will contact you to discuss program fit and participation.
Accessibility and Participation Support
Does the student have a disability, diagnosis, IEP, 504 Plan, accommodation plan, communication need, sensory need, behavioral support plan, or other information that may affect safe and successful participation?
Which areas may require support?

Other
Would you like YEAT UP to contact you before enrollment to discuss support needs?
Have you completed YEAT UP’s separate Accessibility & Participation Support Form?
Optional: Supporting plan or document the family chooses to share

Cancelof
Health, Allergies and Medication
Does the student have allergies, medical conditions, dietary restrictions, or health considerations staff should know for safe participation?
If yes, please describe the condition or allergy, common signs, triggers, restrictions, and response instructions.
Does the student carry or require emergency medication while attending?
Medication name and purpose
Storage and use instructions for the medication
Does the student have food allergies or dietary restrictions?
If yes, please provide details, including whether exposure, ingestion, or cross-contact is a concern.
Primary physician name

First NameLast Name
Primary physician phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contacts
Emergency Contact 1 Full Name

First NameLast Name
Emergency Contact 1 Relationship
Emergency Contact 1 Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Full Name

First NameLast Name
Emergency Contact 2 Relationship
Emergency Contact 2 Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
If guardians cannot be reached, may YEAT UP contact the listed emergency contacts?
Emergency Medical Contact Authorization
Authorized Pickup and Dismissal
Standard dismissal method

Other
Authorized pickup adults
Acknowledgments
Pickup restrictions or special dismissal instructions
Do not list a person as restricted unless you are authorized to make that restriction. YEAT UP may request supporting documentation when necessary.
Media and Communication Consent
Media release for your student
If limited permission, describe any restrictions
May YEAT UP send program updates, schedule changes, enrollment information, and operational messages by email/text?
May YEAT UP send marketing announcements and event promotions?
Program Policies and Parent Responsibilities
Additional Information
What do you hope your student gains from YEAT UP?
Is there anything else we should know before reviewing enrollment?
How did you hear about YEAT UP?

Other
Certification and Electronic Signature
By signing, I certify that I am the student’s parent/legal guardian or otherwise authorized to enroll the student; the information provided is accurate; and I have reviewed and accept the acknowledgments selected above.
Parent/Guardian Full Name

First NameMiddle NameLast Name
Relationship to Student
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Electronic Signature Acknowledgment
Should be Empty:

YEAT UP Membership Enrollment Form

Student Information

Parent/Guardian Information

Program Selection

Student Interests, Learning and Participation

Accessibility and Participation Support

Health, Allergies and Medication

Emergency Contacts

Authorized Pickup and Dismissal

Media and Communication Consent

Program Policies and Parent Responsibilities

Additional Information

Certification and Electronic Signature