Youth Development Services After School Program Enrollment Form

Calumet City Youth Development Services Afterschool Program Enrollment Form

Calumet City’s Youth Development Services program is an out-of-school time program offered free of charge through a federal grant administered by the Illinois Department of Human Services. The program offers academic support, academic enrichment, college and career readiness, and recreational opportunities for participants, and it also serves participants’ families. To get the full benefit of the program, your child should attend daily. Participants who do not attend regularly (80 percent of the time) may be dropped so other participants have the opportunity to participate.

Please complete and submit one form per student being enrolled in the Youth Development Services after school program.

Child’s Name: *

Enter child's full name

Date of Birth:*

Child's birthdate

Grade:*

School Attending:*

the topic of your message

Special Interests/School Activities: *

Parent/Guardian Name: *

Your full name

Address: *

Your address including city state and zip code

Home phone:

Your home phone number

Cell phone:*

Your cell phone number

Work phone:

Extension

Email address:

Please list any medical conditions, drug allergies or food allergies your child may have:

Emergency Contact if we are unable to reach a parent/guardian. If a parent/guardian is not available, the person listed below must be available. *

Phone: *

Relationship to child *

Please list the names of people to whom we may release your child. *

My child’s photo may be used on flyers, website, etc: YesNo

Parent Signature: *

Today's Date: *