BSASC Student Application (English)

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This form is for the youth after school student application.

Site: *

Richmond Heights Middle School (Program Times: Mon-Thurs from 4:00 PM-6:00 PM)

Palm Glades Preparatory Academy (Program Times: Mon-Thurs from 3:10 PM-5:10 PM)

Miramar Multi-Service Complex (Program Times: Mon- Thurs from 2:30 PM-5:00 PM)

Pines Middle School

Has your child ever participated in our Be Strong After School Club program? *

Yes

Child's First Name: *

Child's Last Name: *

Child's Date of Birth: *

YYYY

Child's Gender *

Miami-Dade County Public School ID Number: *

Broward County Public School ID Number: *

Child's School Name: *

Other Language(s) Spoken in the Home: *

Child's Home Address: (Include Apt.) *

Your City: *

Your Zip Code: *

Child's Current Grade: *

Child's T-Shirt Size (Please note shirts come in adult sizes): *

Child's Race (Select One): *

Child's Ethnicity: *

Is your Child Proficient in English? *

Yes

Is your child currently involved in or participating in any sports activities? *

Yes

Does Your Child Have Health Insurance? (ex. Private Insurance, KidCare, Medicaid) *

(If not, we may be able to help you find affordable coverage-call 211 or visit www.thechildrentrust.org) Please note that The Children's Trust may Contact you via postal mail, email and/or text to ask about your satisfaction with these services, and to make you aware of other Trust-funded programs, initiatives and events you may be interested in.

Yes

Child’s Insurance Information

(If child has no current insurance coverage, please select “N/A” below for not applicable.)

Carrier: (If your child has no current insurance coverage, please select “N/A” below for not applicable.) *

Doctor’s Name: (If your child has no current insurance coverage, please select “N/A” below for not applicable.) *

Phone Number: (If your child has no current insurance coverage, please select “N/A” below for not applicable.) *

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