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Big City University Elementary After School Program Application 2025-2026
Please complete the form below. Required fields marked with an asterisk *
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What grade will your child be in during the fall 2025-2026? *
Child's First Name: *
Child's Last Name: *
Student Birthdate: *
MM
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DD
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YYYY
What school does your child attend? *
Home Street Address: *
City: *
State: *
Zip/Postal *
Home Phone Number: *
Cell Phone Number: *
Student's Sex: *
Ethnicity (Please check all that apply): *
Required
Parent's Email Address: *
List other children in the family and relationship to the student: *
Custody
Any custody issues we should be aware of? *
If yes, please explain what the issues are. *
Father's Name: *
Father's Cell phone number: *
Father's Street Address *
City
State: *
Zip/Postal *
Father's employed by: *
Father's Work Phone Number: *
Mother's Name:
Mother's Cell Phone Number:
Mother's Street Address *
City
State: *
Zip/Postal *
Mother's Cell Phone Number: *
Mother Employed by: *
Other Custody:  Legal Guardian's Name: *
Street Address
City
State: *
Zip/Postal
Legal Guardian's Home Phone Number: *
Legal Guardian's Cell Phone Number: *
Legal Guardian's Employed by: *
Legal Guardian's Work Number: *
Legal Guardian's Email: *
Relationship to Student: *
Special Services the Student receives.  (Please check all that apply):
First emergency contact name and contact number: *
Second Emergency Contact Name and Number: *
Third Emergency Contact Name and Phone Number: *
Medical Information:  My student has the following health conditions that may require special care or supports during extended programming hours.
Please list all Food Allergies:
Other health condition(s):
Does your child qualify for free and/or reduced lunch? *
What is the first language your child learned to speak? *
What language does your child speak at home? *
What language do others speak in your child's home? *
What language do others speak in your child's home? *
Where does your student stay at night? *
Other (Explained)
The information provided above is true and accurate to the best of my knowledge; It is my responsibility to notify the school if my child's medical condition changes and/or they have developed any medical needs that may require attention during after school program hours. Yes, the After School Program may use over-the-counter first aid products as needed for my student as they have no known sensitivity to these items. *
Names of Individuals APPROVED to check out my child: *
I have completed the general, medical, and pick-up information.  I understand that someone over the age of 18, must present identification every day, and sign out the student at the end of the program night.  Typing or signing your name denotes agreement: *
I understand the attendance in the after school program is a very important piece of the grant funding.  I will make every effort to have my student attend the after school program each Monday-Thursday.  Failure to attend can cause your student to lose their spot in the after school program.  Typing or signing your name means an agreement: *
The Tennessee Department of Education partners with the University of Tennessee Social Work Office of Research and Public Service to evaluate extended learning programs funded by (Nita M. Lowery 21st Century Community Learning Centers /Lottery for Education Afterschool Programs) grants. 
Part of that evaluation includes a survey for students in grades 3-12. The survey is anonymous: your child will not be asked to provide their name when they complete the survey. The survey asks about your child’s experience of the extended learning program and their response will support continued high-quality programming. Please indicate below if you consent to have your child participate in the survey. 
 *
Required
I agree to allow my child to be photographed and allow these photos to be used for marketing or grant reporting.  Typing or signing your name is agreement and consent. *
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