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Engaging Youth, Engaging Neighborhood Youth Application | Winter 2018
There is no cost for this program if you are a South Bend Resident.
Parent/Guardian Name (s): *
Your answer
Address: *
Your answer
City: *
Your answer
Zip: *
Your answer
Home Number:
Your answer
Cell Number:
Your answer
Work Number:
Your answer
PARENT Email Address: *
Your answer
1st Child Name: *
Your answer
Date of Birth: *
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DD
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Sex: *
Current Grade:
Your answer
School: *
Your answer
Primary Teacher's Name:
Your answer
Any academic or social concerns? If yes, please explain.
Your answer
STUDENT Email (if available)
Your answer
Student Cell Number (if applicable):
Your answer
Fill Out for additional Child(ren)
2nd Child Name:
Your answer
Date of Birth:
MM
/
DD
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YYYY
Sex:
Current Grade:
Your answer
School:
Your answer
Primary Teacher's Name:
Your answer
Any academic or social concerns? If yes, please explain
Your answer
STUDENT Email (If available):
Your answer
Student Cell Number (if applicable):
Your answer
Ethnicity: (information collected for statistical information only)
Primary Language Spoken at home:
Your answer
Other languages spoken at home:
Your answer
Free or Reduced Lunch: (information collected for statistical information only)
Neighborhood Association/Organization related to your place of residence (if known). NA Map at nrc4neighborhoods.org
Your answer
Pick Up Procedure(s):
1. Name, Relationship, Home Number, Cell Number *
Your answer
2. Name, Relationship, Home Number, Cell Number
Your answer
Is your child allowed to walk themselves home or ride their bike home alone? *
List ALL persons who are allowed to pick up your child(ren). These people must bring their picture ID. It is helpful if you call us in advance when anyone from this list is picking up your child.
Your answer
Food allergies for instructors to be aware of:
Your answer
For the student to complete
Please have each student participating fill out this form.
I want to participate in this after school program because:
Your answer
I am a leader at my house.
I am a leader at school.
I am a leader in the community or church
I think I know a lot about South Bend
I am a self-confident person in school.
I am a self-confident person outside of school.
I am talented at something other than "school."
I am proud to live in South Bend
I know how to help improve my community.
Participation and Commitment Requirements:
By agreeing to participate in this after school program you are committing to attending the EYEN workshop on Wednesdays (Jan 24th-April 25th, 2018) from 4:30-6:00 pm. Participants in this program will build, draw, write, read, do photography, and participate in other activities designed to help students have fun while developing their leadership and artistic gifts, and boosting their literacy skills.
Child Signature *
Your answer
Parent Signature *
Your answer
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