This form must be completed in its entirety even if your child has attended Jefferson in the past.

Filling this form out does NOT hold a spot for your child in our program! Your child's spot is not guaranteed until registration and payment are made. This is step one in the process. Be sure to arrange bussing with the Ken-Ton Transportation Department ASAP as the Jefferson Youth Center DOES NOT do anything with bussing. Their phone number is 716-874-8611.

Question Title

1. Your Child

Question Title

2. Child's Sex (Required.)

Question Title

3. Child's Date of Birth (Required.)

Question Title

4. Child's Incoming Grade (as of September 2026) (Required.)

Question Title

5. Child's School (as of September 2026) (Required.)

Question Title

6. Child's Primary Address

Question Title

7. Who resides in the household where the child lives? Check all that apply. (Required.)

Question Title

8. Primary Parent/Guardian (Required.)

Question Title

9. Secondary Parent/Guardian (if applicable)

Please list AT LEAST two people (other than the parent/guardians listed above) to contact in case of an emergency if a parent cannot be reached. These individuals will be authorized to pick-up your child.

If an individual is not authorized to pick up your child, the front desk WILL NOT under no circumstances allow the child to be sent home with them.

**If at any point you would like to add/remove an individual from being authorized to pick up, please email Youth Recreation Coordinator, Julianna at jargenio@tonawanda.ny.us

Question Title

10. Emergency Contact / Authorized Person To Pick Up My Child #1 (Required.)

Question Title

11. Emergency Contact / Authorized Person To Pick Up My Child #2 (Required.)

Question Title

12. Emergency Contact / Authorized Person To Pick Up My Child #3 (optional)

Question Title

13. Emergency Contact / Authorized Person To Pick Up My Child #4 (optional)

Question Title

14. Emergency Contact / Authorized Person To Pick Up My Child #5 (optional)

Question Title

15. Emergency Care

Question Title

16. Does your child require staff supervision at more than a 10:1 ratio to safely participate in our program?

Question Title

17. Does your child receive special services (IEP, 504, Speech, OT, PT) in any other settings (school, home, other) currently or in the past?

Question Title

18. Will your child be able to transition successfully between activities and participate in group play?

Question Title

19. Please select any allergies or food allergies/restrictions your child has. (i.e.- peanut allergy, vegetarian, etc.)

Question Title

20. Does your child take any medications or have any medical conditions we should be aware of?

We do not have a nurse on staff during the After School Program. Any medications your child will need at the JYC must be kept in their backpack and be self-administered.

Children with allergies, seizure disorders, diabetes, or any other chronic health condition must submit a current action plan to Youth Recreation Coordinator, Julianna at jargenio@tonawanda.ny.us to have on file, in case of emergency.

Question Title

21. Please let us know about any recent surgery or serious injury (type & date)

Question Title

22. Chronic or recurring illness, condition, or diet

Question Title

23. Does your child have any restrictions on activity?

Question Title

24. Is there other information that our staff should be aware of that would make your child's experience at JYC successful?

Question Title

25. What days of the week do you anticipate your child attending Jefferson? (Required.)

Question Title

26. What time do you anticipate picking your child up in the evening? (Required.)

Question Title

27. How did you hear about Jefferson Youth Center After School Kids Club?

Question Title

28. What are the top factors influencing your decision to send your child to Kids Club?

T