PYI 2014 Application
GRADES K - 12
Orientation Date: ___________
Application Received: _______
Class Assigned: ____________
Dismissal Method: __P / __W
Please note: All information requested on this application must be completed or application will not be accepted.
A SEPARATE application must be completed for each child who will be attending the program.
STUDENT INFORMATION (Please Print Neatly)
Last Name: ____________________________________
Childs Date of Birth: ________________
First Name: _____________________________________
Childs Age: __________
Childs Gender: [ ] ~ Male // [ ] ~ Female
Street Address: ________________________________________________________________
Apt: ____________
City: _______________________________________
Zip: _____________
State: ______________
School Child Attends: _________________________________________________________
Grade: ___________
PARENT/LEGAL GUARDIANS INFORMATION
Parent/Legal Guardian Full Name: ______________________________________________________________________
Your Relationship to Child: ____________________________________________________________________________
Home Phone: ___________________________________
Work Phone: ______________________________________
Cellular Phone: _________________________________
Alternate Phone: ______________________________
Email Address: ________________________________________________________________________________________
EMERGENCY CONTACT INFORMATION
(These individuals must be available between 1:00pm and 4:00pm, if you are not available)
Full Name: ________________________________
Relationship to Child: __________________________________
Home Phone: _____________________________
Alternate Phone: _______________________________________
******************************************************
Full Name: __________________________________
Relationship to Child: ____________________________________
Home Phone: _______________________________
Alternate Phone: _________________________________________
MEDICAL / DIETARY NEEDS
Please list all medical, dietary needs, restrictions and or medication needs that your child may have during program hours.
Medical Needs / Restrictions:
_______________________________________________________________________________________________________________________________________
Dietary Needs / Restrictions / Allergies:
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
Please detail any activities that your child cannot participate in:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
EMERGENCY MEDICAL CARE
If your child requires emergency medical care and you cannot be reached, you give consent to Positive Youth Impact to obtain the necessary
medical care for your child. You agree to pay all of the costs associated with the emergency medical care that your child receives. You
understand that every effort will be made to contact you before and after medical care is provided. After treatment, your child will be released to
one of the individuals listed as an emergency contact or other authorized pick-up individual, in the event you are unavailable.
Health Insurance Carrier: __________________________________________________________________________________________
Policy Holder: ____________________________________________________________________________________________________
Identification Number: ______________________________
Group Number: ___________________________________
Students Doctor: ___________________________________
Phone: __________________________________________
Parents / Legal Guardians Signature: ______________________________________
Date: _______________
DISMISSAL OF CHILDREN
Dismissal begins at 4:00pm! Parents are asked not to pick-up their children before the scheduled dismissal time (4:00pm) as it is
disruptive to program operations. Students who are authorized to walk home alone will be escorted out of the building at that time.
All other students will await pick-up by his/her parent, guardian or usual authorized pick-up individual listed on this application. All
students must be picked up no later than 4:15pm! If any other arrangements are desired or necessary, they must be communicated in
advance and in writing to the Program Administrators. Once the child has been released to the parent/guardian or authorized pick-up
individual, Positive Youth Impact will bear no responsibility. Please sign below indicating that you have read and understood the
above.
Parents / Legal Guardians Signature: _______________________________________ Date: _______________
DISMISSAL METHOD ~ Check ONE box only!
[ ] ~ I give my child permission to walk home alone after dismissal at 4:00pm.
[ ] ~ My child will be picked up by me or by one the individuals listed below.
PICK-UP AUTHORIZATION
* Anyone picking up the student that does not attend the program MUST be 16 years or older. No exceptions.
(All pick-up persons must have photo identification! Your child will not be released to anyone not listed below!)
Full Name: ________________________________
Relationship to Child: ______________________________
Home Phone: ______________________________
Alternate Phone: __________________________________
******************************************************
Full Name: __________________________________
Relationship to Child: _____________________________
Home Phone: ________________________________
Alternate Phone: _________________________________
******************************************************
Full Name: __________________________________
Relationship to Child: _____________________________
Home Phone: ________________________________
Alternate Phone: _________________________________
UNDER NO CIRCUMSTANCES will the following individual(s) be allowed to pick up student:
* If you have listed a biological parent, a legal document issued by the court must be submitted.
Full Name: ________________________________
Relationship to Child: _____________________________
Full Name: ________________________________
Relationship to Child: _____________________________
