EU Enrollment 25-26 - United Way of Westchester and Putnam

Education United After-School Program Enrollment

Before enrolling your child in the program, please complete the following medical forms.

REQUIRED FOR ALL: An up-to-date physical form

IF CHILD HAS ALLERGIES OR OTHER SPECIAL NEEDS: Allergy and Medical Needs Form

IF YOUR CHILD NEEDS AN EPIPEN: Epipen Administration Form

These forms will be uploaded when you complete the student registration form linked below.

If any of the following apply, please provide copies of relevant legal documents: Custody agreement or court order, Guardianship papers, Foster care placement documentation, Power of attorney for childcare decisions, Any court orders restricting contact with specific individuals.

Additionally, an optional photo of your child will be uploaded when you complete the student registration form, which can be found linked below.

STEP 3 - Student Enrollment

Step 1 of 7

Student Information

Student's Full Name:(Required)

Student's Preferred Name:(Required)

Date of Birth:(Required)

Child's Photo (optional)

Max. file size: 1 GB.

Student's Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone:(Required)

Languages Spoken at Home:(Required)

Racial/Ethnic Group(Required)

If Other:

Attending School:(Required)

Grade:(Required)

Student's Primary Teacher (required for grades 1-5, write N/A if not applicable)(Required)

How many days (Monday-Thursday Sep 29 - June 18 ) you interested in?(Required)

Four days a week.

Three days a week.

Two days a week.

I am open to what is available.

Please list the days that you want your child to attend the program.(Required)

Do you need free Lyft rides to pickup your child?(Required)

Yes

Name of Person Enrolling Student:(Required)

Relationship to Student(Required)

If other, please explain here.

Address of Person Enrolling Student (if different from student -fill in with N/A if not applicable)(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email of Person Enrolling Student:(Required)

Phone Number of Person Enrolling Student:(Required)

For the safety and security of your child, we need to understand their custody situation.Please check all that apply:(Required)

Child lives with both parent

Child has a shared custody arrangement

Child lives primarily with one parent

Child lives with grandparent(s) or other relative

Child is in foster care

Child lives with legal guardian (non-relative)

Other

Legal Documentation Required

Max. file size: 1 GB.

If any of the following apply, please provide copies of relevant legal documents: Custody agreement or court order Guardianship papers Foster care placement documentation Power of attorney for childcare decisions Any court orders restricting contact with specific individuals

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Education United After-School Program Enrollment

STEP 3 - Student Enrollment

Student Information

Emergency Contacts

Release of Student at Dismissal

If no, my child will be picked up after school by me or those individuals llisted as an emergency contact.

Student Health Information:

Does your child have any of the following?

*Please note medications taken or administered at the program, including an Epipen will need written parent/guardian consent and health care provider order.

Agreements

Student Data Requirements and Surveys/Interviews Consent

Signature of Consent

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