2025 Hope Sessions After-School Program

(Please complete one form for each child. Accepting students currently in grades K-8.)

PROGRAM HOURS: Tuesday, Wednesday, Thursday; 3:00pm -6:00pm.

INSTRUCTIONS: Please complete one form for each child enrolled in Hope Sessions After-School program.

If requested information is non-applicable, mark N/A. If requested information is unavailable or unknown at this time, mark U/A.

SPACES ARE LIMITED. After your application is reviewed, you will be contacted by the Program Director

Today’s Date (MM/DD/YEAR):

Parent/Guardian's Information

Home Phone Number:

This address will receive a confirmation email

Relationship to Child:

Father Mother Legal Guardian Foster Parent Grandparent Other

Does this child currently live with you?

Yes No

If no, what is the child's home address?

Child’s Demographic Information

Child's Last Name:

Child's First Name:

Child's Middle Name:

Child's Preferred Name or Nickname:

Child’s Date of Birth (MM/DD/YEAR):

Child’s Gender:

Male Female

What is your child’s primary/native language (language spoken at home)?

Child’s Race/Ethnicity (Check One Only):

African American/Black, non-Latino Native American/Indian or Alaska Native Asian American Native Hawaiian or Pacific Islander Latino/Hispanic European American/White, non-Latino Mixed Heritage Other

What other academic enrichment or extra-curricular activities does your child participate in during the summer or academic school year (e.g. organized sports, music or dance lessons, academic tutoring, clubs, etc.)?

What are your child’s hobbies or interests?

What type of school does your child attend?

Public Charter School Faith-Based Private Home School Other

What is the name and location of the school your child currently attends?

What grade is your child currently in this school year? (school year 2024-2025)

K 1 2 3 4 5 6 7

Has your child been in foster care at any point in his or her life?

Yes No

Child’s Academic Information

Does your child participate in any of the following educational programs (check all that apply)?

Bilingual Education ESL/LEP Special Education Gifted and Talented 504B Plan Other None

Has a doctor, health professional, teacher, or school official ever informed you that your child has a learning disability or social-emotional (behavioral) disability? *

Yes No

If yes, please explain:

Does your child have an Individualized Education Program (IEP) on file?

Yes No

Has your child ever repeated a grade?

Yes No Unknown

Has your child attended the Bridge to Freedom Summer Program before?

Yes No

What is your child’s reading proficiency level?

Above Grade Level At Grade Level Below Grade Level Non-applicable Unknown

Child’s Medical Information

Does your child have health insurance?

Yes No

If yes, please provide the information requested below: Health Insurance Carrier:

Please explain any special procedures that should followed in the event that your child has a medical emergency: *

Has a doctor or health professional ever informed you that your child has any of the following medical conditions or disabilities? *

Asthma Hearing Problems Vision Problems Attention Deficit Disorder (ADD) Attention Deficit Hyperactivity Disorder (ADHD) Depression or anxiety problems Behavior or conduct problems Bone, joint, or muscle problems Diabetes Autism Obesity Allergies (allergic reactions) Other None

Any developmental delay or physical impairment (please describe below)

Does your child currently need or use medication prescribed by a doctor?

Yes No

If yes, please be sure all medication(s) are dispensed daily before attending programming.

If there is anything else that you would like to share about your child, please indicate here (ie. List allergic reactions….)

2025 Hope Sessions After-School Program

Description

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