Future Leaders Organization Out-Of-School Program Application! SUMMER 2024

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

119 W Bayview Avenue, Pleasantville, NJ 08232

Email *

Student's Name *

Last and First Name

Home Address *

Parent phone number *

School presently attending *

Grade (as of September 2023 school year) *

School State ID Number *

Students' T Shirt Size *

Youth Small (6-8)

Youth Medium (8-10)

Youth Large (10-12)

Youth XL (14-16

Adult Small

Adult Medium

Adult Large

Adult XL

Other:

Gender *

Male

Female

Date of Birth *

YYYY

Native Language(s) spoken at home *

ESL *

Yes

Required

Lunch: *

Free

Reduced

Paid

Veteran Status of Family *

Student Ethnicity *

African American

Asian

Hispanic

Caucasian

Haitian

Other:

Parent/Guardians Name: *

Address: *

Cell/Home Phone Number *

Work Phone Number: *

Place of Employment *

Emergency Contact Name *

Cell Phone Number *

Other Phone Number

Relationship to Student *

Additional Emergency Contact *

I hereby give permission for any and all medical attention necessary to be administered to my youth__________________________________ in the event of accident, injury, sickness, etc., while they are under the care of the person(s) designated below, until such time as I may be contacted. *

Known allergies or medical conditions of youth *

Medication youth takes: *

I give _________________________________, permission to be involved in the educational program and in the promotion (photos) and evaluation of these programs. *

I give my youth permission to walk home from The After School Experience at 119 W Bayview Avenue, Pleasantville, NJ 08232. *

Yes

If not what address would you like the youth to be dropped off at (School Year ONLY)

Please release my youth to the following people other than Parents, ONLY: (LIST ALL) *

Health Declaration: For safety and well being of the staff, students, parents, and collaborators remains our #1 priority. Please Review and acknowledge the following on behalf the students and your family. *

I agree

I disagree

I understand that my child or family member will not be able to attend the program with a temperature 100 degrees or higher on any given day. Sign initials below

I understand I must pick my child or family member up if he/she develops a temperature higher than 100 degrees while attending the program and can not return for 2 days. Sign initials below. *

Has the student received the COVID-19 vaccine?

Yes

Clear selection

Health Declaration *

My child is in good health and can participate in the normal activities of the program and has no conditions that require special accommodations

My child can participate in the normal activities of the program but has conditions or special needs that require special accommodations as indicated below.

Other:

Please list any allergies, medical conditions, including chronic health problems (such as asthma, seizures, behavior disorders, special needs, etc.) *

Parent/ Family member's signature and Date *

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms