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: _____________________________