LaRosa Youth Club | Out of School Time Programming Application 2026-2027

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This form is to be completed in entirety. A form must be completed for each child. Once application submitted, you will be contacted within 72 hours to verify application and be provided a start date and payment amount for your child. Should you have any questions, while completing this application, please feel free to reach out to 267-273-6002 or 412-679-3929 or email admin@larosayouthclub.org

Email *

Child First Name *

Child’s Last Name *

Child DOB (ages 5-18) *

YYYY

Child Race/Ethnicity *

Home Address *

County Child Resides *

Allegheny County

Westmoreland County

Other:

Child’s School District *

School Child Attends *

Child Current Grade Level for 2025-2026 School Year *

Returning Student *

Returning

This is a new student. Welcome :)

Required

What is you household size? *Please include ALL household members. *

Will you have more then one-child enrolled into the Out of School Time Programing? If so, please write their (names) below to help with streamlining application. If this does not apply, write N/A. *

Parent 1/Guardian 1 Name *

Parent 1/Guardian 1 Phone Number *

Parent 1/Guardian 1 EMAIL (providing email is giving consent to receive emails from LaRosa regarding events, cancellations, closures, and updates regarding your child). If you do not agree put N/A.
*

Parent 2/Guardian 2 Name

Parent 2/Guardian 2 Number

Parent 2/Guardian 2 EMAIL (providing email is giving consent to receive emails from LaRosa regarding events, cancellations, closures, and updates regarding your child). If you do not agree put N/A.

Please list at least 1 emergency contact NAME, PHONE NUMBER, and ADDRESS.

*This CANNOT be the same as a guardian/parent listed above

Please list at least the emergency contact PHONE NUMBER.

*This CANNOT be the same as a guardian/parent listed above

Please list at least the emergency contact ADDRESS.

*This CANNOT be the same as a guardian/parent listed above

I Authorize the following individual(s) to pick my child up in my absence.

*Please provide Name, Phone Number, and Address of Individual(s). Consent, can be revoked anytime, in writing.

Any special custody arrangement(s) that we should be aware of (PFA, custody orders, ect). *

Yes I will provide copy to the office, prior to my child's enrollment.

Required

Will your child be walking at dismissal 4:00pm (Child must be at least 10 years of age to be released without an adult). Child will not be released if deemed unsafe by LaRosa staff (ie. weather road conditions, safety issues reported by police, or any other scenario deemed unsafe). Parents will be notified if this occurs. *

Yes (Your selection of yes, is your agreement to the above, revocation of consent, can be done at anytime by staff (parent will be notified), or parent by emailing LaRosa.

No (My child will be picked up by 6:30pm by myself or someone I designate in writing).

List any allergies, medical condition, or extra support/accommodation that your child may be in need of. If this does not apply, please write N/A. *

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