Community After School

Please fill in the form below:

Best Email Address:

Child's First name: Child's Last name:

Date of Birth: Gender:

Address: APT #: City: Zip:

Last 4 digits of Child's SS#:

School Name: Student School ID#:

Current Grade:

Country of Birth: Cultural Influence: If not in the list, please type it in the box

Language spoken at home:

Ethnicity: Race:

Mom's Name: Mom's Number:

Dad's Name: Dad's Number:

"The Children's Services Council of Broward County ("CSC") collects and uses the social security numbers of participants of CSC-funded programs and the parents/guardians of such participants so that CSC may collect and use data from other agencies for comparison purposes in order for CSC to track and measure the impact of CSC-funded programs. This also helps CSC with maintaining and improving successful programs and services. All individual information is safeguarded and will not be disclosed. CSC's collection of social security numbers from its participants and the parents/guardians is critical for the performance of CSC's duties and responsibilities as prescribed by law. Social security numbers collected by CSC shall not be used by CSC for any purpose other than the purpose provided in this written statement."

If you are rewarded a scholarship, your child must stay everyday for the first 2 hours of the program.

Submit your 1040 Tax Return to complete your application. It must contain child's name and Adjusted Gross Income. Email to mike@communityafterschool.com or fax to 954-255-0037.

Signature of parent/guardian: Date: