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2025-2026 Mizizi Afterschool Program Interest Form
The Mizizi Afterschool Program serves to support children and their parents. Mizizi is a grassroots effort founded on the principle that providing families with the tools of greatness will lead to their child's success.
The Mizizi program is for grades 1st through 5th for the 2024-2025 school year.

The program is Monday - Thursday after school from 2:30PM-6:00PM and will begin September 15th, 2025. We will run through May 2026. We will be off for all JCPS holidays and off days. 

Filling out this form does not guarantee a spot in the 2025-2026 Mizizi program. We will contact you with more details and availability for the program once the form is completed. 

ONE CHILD ONLY PER FORM. Please fill out an additional form for each one of your children. Thank you!

Questions? Please reach out to our Youth Admin, at YouthAdmin@playcousinscollective.com.
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Email *
First Name *
Last Name *
Phone Number *
Current Address
*
First Name of student *
Last Name of Student *
Child's Race & Ethnicity (mark all that apply) *
Required
Birthday of youth *
MM
/
DD
/
YYYY
Child's Grade 2024-2025 School Year: *
Child's School *
If you choose "Homeschooled" or " Private School" for the question above please list the school name here or give a brief description of the homeschool program:
Child's School Dismissal Time: *
Will your child need transportation to the program?  If so from where will they need to be picked up?
*Limited space is available, priority will be given to children near in proximity to Mizizi. 
Please list any medical conditions or non-food allergies : *
Please list any allergies to food or dietary restrictions: *
Do you believe your child is reading on grade level?
Yes
Definitely not, and was not last school year
Yes, they were on grade level at the start of the year
Clear selection
Do you believe your child is writing on grade level?
Yes
Definitely not, and was not last school year
Yes, they were on grade level at the start of the year
Clear selection
Do you believe your child's math skills are on grade level?

Yes
Definitely not, and was not last school year
Yes, they were on grade level at the start of the year
Clear selection
Does your child have an IEP (individualized education plan/program)?
Clear selection
What social and emotional skills is your child in need of strengthening? *
Required
What skills and subjects does your child most enjoy and succeed at? *
Required
Is there anything else we should note about your child, to ensure their comfort, success, and joy during our program?
Please list any questions you have for us:
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