Afterschool Application

PLEASE NOTE: filling out this form does not guarantee your child a spot in our program
Child's Full Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Birth Date*
MM
DD
YYYY
Child's School*
Current Grade Level*
Current Age*
Legal Parent/Guardian Name*
First Last
WORKING Parent/Guardian Phone*
Alternate Parent/Guardian Phone
Parent/Guardian Email
Who Does The Child Live With Most Of The Time*
(Mom, Dad, Grandparent, etc.)
Number of People Living in Home*
Yearly Household Income*
Has Your Child Ever Been Arrested?*
If Yes, How Many Times?*
How Many Times Has Your Child Moved In The Past Year?*
Which Program Will Your Child Be Attending?*
Would You Like Your Child To Potentially Be Matched With A Mentor?*

Is There A Parent In Jail Or Prison?*
Which Parent Is In Jail Or Prison?*
Has A Parent Attended College?*
Has A Parent Graduated From College?*
Please List Additional People Who Are Authorized To Pick Up Your Child*
Person 1 Person 2
Is There Anyone Who CANNOT Pick Up Your Child?*

Legal Release Form
Consent*
I/we by law may do so; authorize the administration of medical treatment to he/she who is subject of this form. I/we understand all reasonable safety precautions will be taken at all times. I also understand that in the event medical intervention is needed every attempt will be made to contact the above persons immediately. I/we recognize that one of the primary purposes of Rise Up! is to maintain and improve school performance. This release gives permission for the Johnson City School System to discuss the behavior and academic performance and receive a copy of my child’s report card. I/we do herby further release and indemnify, Rise Up!, The Refuge and any other facility and their staff and or officers from any cause of action resulting from circumstances which may arise from any activity and or field trip and do agree to hold Rise Up! and their staff and officers and agents blameless in the event of emergency action on behalf of my child named above. I/we give permission for Rise Up! to publish my child’s picture or video of my child. I/we give permission for the school to release my child to Rise UP! staff for transportation to program. Rise Up! agrees, warrants, and assures that no person shall be excluded from participation in, be denied benefits of, or be otherwise subjected to discrimination on the grounds of disability, age, race, color, religion, sex, national origin or any other classification protected by Federal, and Tennessee State constitutional or statutory law.

Emergency Information
Emergency Contact Name*
Name of a person, other than parent, authorized to act for parent in case of emergency.
First Last
Emergency Contact Phone Number*
What Is The Emergency Contact's Relation To The Child? (Parent, Grandparent, Friend, etc.)*

Child's Education Information
Child's School*
Child's Current Grade*
Child's Teacher's Name*
Does Your Child Receive Free Or Reduced Price Lunch At School?*

Medical Information
Does Your Child Have Any Physical Or Medical Conditions?*
(if none, enter n/a)
Does Your Child Have Any Behavioral Or Mental Conditions?*
(if none, enter n/a)
Is Your Child Currently On Any Medications?*
(if none, enter n/a)
Does Your Child Have Any Allergies? (food, insects, medication, etc.)*
(if none, enter n/a)
Name Of Primary Care Physician*
Physician Phone Number
Medical Insurance Provider
Policy Number
Insurance Phone Number

Special Permission Form
Licensing Disclosure*
I understand that Rise Up is not licensed, and is not required to be licensed by the sate as a childcare agency.
I understand
Field Trip Permission Form*
My child has permission to go on field trips arranged by Rise Up! These field trips will be supervised by adults and will be in accordance with Johnson City Board of Education policies and procedures. Parents will receive notice before each trip.
I agree

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After School Application

Step 1 of 7

PLEASE NOTE: filling out this form does not guarantee your child a spot in our program

Legal Release Form

Emergency Information

Child's Education Information

Medical Information

Special Permission Form

Person 1	Person 2