After School Program – Application | LUM Client Information

BEFORE YOU BEGIN — Please review the application first and be sure that you have all of the information you need before filling out the form. You will NOT be able to save your work and return to this form at a later time.

When you have the information you need — fill out the registration form below.

When the registration form is completed and you’re ready — click SUBMIT.
IMPORTANT — Stay on this page until the form is done processing — otherwise, it may not go through. You will receive an email confirming that LUM has received your registration when it is submitted properly. When typing information into this form, please do NOT use only lower case or upper case letter.

After School Program – Important Information, click HERE
After School Program – main page, click HERE

No LUM Program applicant shall suffer discrimination due to his/her race, religion, national origin, gender, age, marital status, physical handicap, sexual orientation, political association or belief, or union affiliation or activity.

Fields marked with an <span class="ninja-forms-req-symbol">*</span> are required

CHILD'S INFORMATION

First Name *

Last Name *

Name child goes by, if different than above

Date of Birth *

Age *

Sex *

Female
Male

HOUSEHOLD INFORMATION

First Name - Parent/Guardian - Primary *

Last Name - Parent/Guardian - Primary *

Date of Birth - Parent/Guardian - Primary *

First Name - Parent/Guardian - 2nd

Last Name - Parent/Guardian - 2nd

Date of Birth - Parent/Guardian - 2nd

Street Address *

City *

State

Zip Code *

5 of 5

Phone - Primary *

Phone - Secondary

Email Address *

TOTAL Household Income for ONE MONTH *

TOTAL Number of Individuals living in this household *

Employer's Name *

Employer's Phone *

Other Children in Your Household -- Name & Date of Birth

Other Children in Your Household Name & Date of Birth

Please list the full Name & Date of Birth for all other children in this household.

Adult who are Authorized to Pick Up Child

ADULTS who are AUTHORIZED to PICK UP Child

Full Name -- Authorized to Pick Up #1

Address -- Authorized to Pick Up #1

Phone -- Authorized to Pick Up #1

Email -- Authorized to Pick Up #1

Relationship to Child -- Authorized to Pick Up #1

Full Name -- Authorized to Pick Up #2

Address -- Authorized to Pick Up #2

Phone -- Authorized to Pick Up #2

Email -- Authorized to Pick Up #2

Relationship to Child -- Authorized to Pick Up #2

Full Name -- Authorized to Pick Up #3

Address -- Authorized to Pick Up #3

Phone -- Authorized to Pick Up #3

Email -- Authorized to Pick Up #3

Relationship to Child -- Authorized to Pick Up #3

EMERGENCY CONTACT INFORMATION

Emergency Contact #1

Emergency Contact #1

Full Name -- Emergency Contact #1 *

Address -- Emergency Contact #1 *

Phone - Emergency Contact #1 *

Email - Emergency Contact #1

Emergency Contact #2

Emergency Contact #2

Full Name - Emergency Contact #2 *

Address - Emergency Contact #2 *

Phone - Emergency Contact #2 *

Email - Emergency Contact #2

HEALTH INFORMATION - for STUDENT

Name - Child's Physician *

Phone - Child's Physician *

Address - Child's Physician *

Has Child - seen a doctor in the last six months? *

Do we have permission to speak to your doctor about your child, if need be? *

Child's General Health (pick one): *

Good
Fair
Poor

Does Child - have an up-to-date Shot Record? *

Does Child - have an emotional disability or mental health condition? *

Does Child - have a physical disability? *

Does Child - have any allergies? *

Does Child - require a special diet? *

If you answered YES to any of the above, please explain:

Does Child - have temper tantrums? *

Has Child - been diagnosed with ADD and/or ADHD? *

Is Child - taking medication for ADD and/or ADHD? *

Has Child - been diagnosed with an Autism Spectrum Disorder? *

Does your child have any medical condition? (example: Asthma) *

If you answered YES, please explain:

Does Child - take any type of medication? *

If you answered YES, please list name of each Medication, Dosage and Time to be taken:

Will this medication need to be administered while at the After School Program? *

Do we have your permission to administer this medication to your child if need be? *

EDUCATIONAL INFORMATION - for STUDENT

EDUCATIONAL INFORMATION for STUDENT

Name of School -- Attending in the Fall *

Grade Level -- in the Fall *

Teacher's Name

Teacher's Phone

Teacher's Email

Names of Other Teachers, if applicable

Permission to Communicate with Teachers *

I give the above school and teacher(s) permission to pass on homework expectations and student information to the employees of the LUM After School Program.

Does Child - have a learning or cognitive disability? *

Does Child - have an Individualized Education Plan (I.E.P)? *

Does Child - have any learning difficulties? *

If you answered YES, please explain:

SPECIAL INFORMATION

Has your child ever attended a child care program? *

If you answered YES, which ones:

My child gets upset when: *

My child calms down when I: *

My child is happiest when: *

Are there any problems concerning your child we should be aware of, for instance medically, educationally or behaviorally? Failure to disclose this information may result in your child being expelled from the program: *

If you answered YES, please explain:

PERMISSION to Attend the After School Program *

My child has permission to attend the LUM After School Program. I understand that every attempt will be made to make the program enjoyable and safe for him/her. However, neither Lafayette Urban Ministry, its Board Members, its staff or volunteers will be liable for any injuries to my child or damages to his/her property resulting either directly or indirectly from this program. I further give permission for emergency medical treatment in case I cannot be reached.

I have read and understand the Permission Statement; and I agree to the terms stated above.

Permission to Transport Child *

I understand that the LUM After School Program transports students from their schools to LUM and schedules field trips to enhance the education and recreation of the students; and that families will be notified of all fields trips in advance.

I give my permission for my child to participate in the field trips; and I give my permission to have Lafayette Urban Ministry transport my child from school to LUM Youth Center and from the LUM Youth Center to the location of field trips.

Food Policy Permission *

I understand that a snacks will be provided by LUM for all Youth Programs and give permission for my children to receive and eat snacks.

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Payment Policies *

I have read, fully understand and agree to the terms of the payment policies for the LUM After School Program. I also agree to pay any fee assessed to my family.

Payment Schedule

Monthly Payment
Weekly Payment

Please choose the Payment Schedule you prefer:

Media Consent *

Occasionally, Lafayette Urban Ministry uses pictures of children who participate in LUM programming for informational or publicity purposes. This can include reproducing pictures on our web site or in a newsletter or newspaper or for promotional pamphlets, or using quotes from participating children for any of the above purposes.

I give my permission for Lafayette Urban Ministry and its staff to use any pictures of or quotes from my child for informational and publicity purposes, including, but not limited to, reproduction in newspapers or newsletters, web sites, pamphlets or other promotional materials.

I give permission for Lafayette Urban Ministry to identify my child by name in captions of pictures of or quotes from my child for informational and publicity purposes, including, but not limited to, reproduction in newspapers or newsletters, web sites, pamphlets or other promotional materials.

These permissions are valid for one calendar year from the date of this application.

I have read and understand the Media Consent Statement; and I agree to the terms stated above.

Discipline/Guidance Policy *

It is very important that a child’s development is nurtured through caring, patience and understanding. However, while caring for your children, we may have to respond to your child’s misbehavior. Hitting, kicking, spitting, hostile verbal behavior and other behaviors which will hurt another child are not permitted.

In response to these behaviors, we will not use:
* Threats or bribes
* Physical punishment, even if requested by the parent
* Deprive your child of food or other basic needs
* Humiliation or isolation

In response to misbehavior, we will:
* Respect your child
* Establish clear rules
* Be consistent in enforcing rules
* Use positive language to explain desired behavior
* Speak calmly while bending down to your child’s eye level
* Give clear choices
* Redirect your child to a new activity
* Move your child to a time-out area for no longer than one minute per year of your child’s age, if necessary

If your child’s behavior is very disruptive or harmful to him/herself or other children, we will discuss the issue with you privately. If the situation can be resolved, the child may remain enrolled. If we are unable to resolve the issue, you may be asked to make other child care arrangements.

I have read and understand the Discipline/Guidance Policy for the After School Program; and I agree to the terms stated above.

As a parent/guardian, you may have some concerns or wish to offer suggestions. Please use the space below for concerns or suggestions. LUM staff may modify the above plan with agreed upon suggestions.

Additional techniques to be used with my child:

Notice to parents and guardians by unlicensed ministries *

I understand that this child care ministry is not licensed under the laws of Indiana. However, I understand that this child care ministry must comply with the state rules concerning sanitation and fire and life safety for the primary use of the structure in which it is conducted. I understand that it is my responsibility to ensure that the nutritional and health needs of my child are met while my child is at the child care ministry.

All the information in this LUM After School Program Application Form is correct to the best of my knowledge. *

Full Name -- Person completing this Registration Form *

Your relationship with the Child? *

I am the child's legal guardian and have the authority to submit this form. *

By submitting this form, you are adding your electronic signature to this application.

If you are a human seeing this field, please leave it empty.