After School Application | Bringing Education to Tomorrow's Youths

Child Information

Number of Children to Enroll

One Two Three Four

Child’s Name

Birth Date

Gender

Male

Female

Child’s Name

Birth Date

Gender

Male

Female

Address (Street, City, State, Zip Code)

Home Phone Number

Identifying Information

Mother’s Name

Home Phone Number

Mother’s Address (Street, City, State, Zip Code)

Mother’s Cell Phone Number

Mother’s Email Address

Mother’s Employer

Mother’s Business Address (Street, City, State, Zip Code)

Mother’s Business Phone Number

Mother’s Direct Phone Number

Father’s Name

Father’s Home Phone Number

Father’s Address (Street, City, State, Zip Code)

Father’s Cell Phone Number

Father’s Email Address

Father’s Employer

Father’s Business Address (Street, City, State, Zip Code)

Father’s Business Phone Number

Father’s Direct Phone Number

Emergency Contacts & Authorizations

Emergency Contacts

Other than Parents or Physicians

Emergency Contact 1: Name

Relationship to Child

Address (Street, City, State, Zip Code)

Phone

Emergency Contact 2: Name

Relationship to Child

Address (Street, City, State, Zip Code)

Phone

Authorized to Take Child

Other than parents

Authorized for Pickup 1: Name

Authorized for Pickup 2: Name

Authorization for Emergency Medical Use

I understand I will be notified at once in case of accident or illness to my child, and I will make arrangements for medical care of my child with the physician or hospital of my choice. If I cannot be reached to make necessary arrangements, or in a critical emergency requiring medical care; I hereby authorize Education Station to contact the following for emergency medical treatment of my child.

Preferred Hospital

Hospital’s Address (Street, City, State, Zip Code)

Hospital’s Phone

Concluding Information

Homework Help and Dietary Needs

Please let us know what academic subjects you would like ES to focus on: Language Arts, Math, Science, Social Studies. In addition for dinner requirements please let us know what special dietary needs you would us to consider.

Child’s Development (Academic subjects, restrictions, allergies, habits, special language, or special dietary needs we should be aware of?)

Agreements

When my child is ill, it is understood and agreed that he/she may not be accepted into school.
I have been informed that a copy of Missouri’s Child Care Licensing Rules is available at the school for review.

I understand that I can ask whether or not a child at Education Station has an immunization waiver.

I have read the parent handbook of Education Station.
I accept full responsibility for my child’s weekly fee of $70.
I understand that space is limited and my application is not accepted until the $25 is paid to secure my child’s spot in the program.

Signature