Middle & High School Application

Name of Student(Required)

Full Name

Date of Birth(Required)

Age(Required)

Please enter a number from 0 to 99.

Gender(Required)

Race(Required)

Hispanic?

Yes

No

Address(Required)

Zip Code(Required)

Cell Phone # of Participant(Required)

Email Address of Participant(Required)

Name of Parent(Required)

Full Name

Name of Parent

Full Name

Cell Phone # of Parent(Required)

Email Address of Parent(Required)

Emergency Contact Name & Number(Required)

Relationship to Participant(Required)

Name of School(Required)

Grade in Fall 2025(Required)

Does Student Receive: Special Education Services (IEP)?(Required)

Yes

No

504 Plan?(Required)

Yes

No

Does your child have any medical condition(s) that will require medication or special attention during program hours?(Required)

Yes

No

Medication(s) and times(Required)

Medication(s) and times

Does your child have any current police or court involvement?(Required)

Yes

No

Does your child receive free and/or reduced lunch?(Required)

Yes

No

Does your family receive housing assistance (Section 8, etc.) and/or TANF benefits?(Required)

Yes

No

Household Income (select one):(Required)

$0-$10,000

$10,000-$15,000

$15,000-$25,000

$25,000-$35,000

$35,000-$50,000

$50,000-$75,000

$75,000+

Number in Household: Children (Under 18)(Required)

Please enter a number from 0 to 10.

Number in Household: Adults(Required)

Please enter a number from 0 to 10.

No weapons or firearms allowed on the premises of Urbana Neighborhood Connections Center. UNCC is not licensed or regulated by the IL Department of Children & Family Services. UNCC may maintain student files in a secured location on-site for up to 5 years after enrollment; thereafter will be destroyed. UNCC is prohibited from discriminating on the basis of race, color, national origin, sexual orientation or identity, disability, or age.

ANTI-BULLYING POLICY Urbana Neighborhood Connections Center views bullying as an extremely serious form of anti-social behavior and takes a zero-tolerance policy pertaining to bullying behavior. Bullying may take a variety of forms such as: physical, verbal, psychological, and emotional abuse. It may also include comments of a racial or sexual nature. All UNCC staff and volunteers are responsible for communicating incidents of such nature with administrative leadership of the center. Parents will be contacted by a member of the UNCC Family to collaborate on a preventative plan of action. As an absolute last resort, if behavior persists, consequences may include removal from activities, suspension, or permanent removal from Urbana Neighborhood Connections Center. AGREEMENT STATEMENT I understand that bullying is not allowed at Urbana Neighborhood Connections Center and that UNCC reserves the right to terminate enrollment of any student(s) involved in recurring incidents that violate the rights of other students.

Signature(Required)

Date

PHOTO RELEASE CONSENT I give permission for Urbana Neighborhood Connections Center to share photo/video footage of my child(ren) on our social media, website, and other marketing materials (banner, flyers, etc.).

Signature(Required)

Date

PAYMENT POLICY I understand that programs cost money to operate properly, and I agree to pay the entirety of the Summer Enrichment Program enrollment fee prior to the start of the program. If I am unable to, I will contact a member of the UNCC Administrative Leadership Team to establish a payment arrangement.

Signature(Required)

Date

CELL PHONE POLICY Urbana Neighborhood Connections Center requires program participants to turn in their cell phones upon arrival at the center to increase their attentiveness and engagement in activities. Cell phones are to be placed in the turn-in tub in the reception area and pick them up upon leaving, unless otherwise instructed by staff or provided with technology break times throughout the programming term. I understand that my child(ren) will be expected to participate in the planned activities for academic enrichment and social development, without the distraction of cell phone use. I may call (217) 954-1749 to reach any staff member or my student during program operation time.

Signature(Required)

Date

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VEHICLE EXPECTATIONS Urbana Neighborhood Connections Center requires all program participants to maintain a safe, respectful environment for every passenger of our van/bus. I understand that: All body parts must be kept inside the vehicle at all times. Noise levels must be kept to a reasonable volume. Feet, backpacks, and other items must remain in the seating area; aisles must be clear. Eating and drinking on UNCC vehicle is not permitted at any time. Damage to the property becomes the responsibility of the parent/guardian.

Signature(Required)

Date

LIABILITY WAIVER I acknowledge that my child’s participation in Urbana Neighborhood Connections Center’s programming is voluntary. UNCC staff are not responsible for lost or stolen items. I release Urbana Neighborhood Connections Center and all involved parties from liability and claims of injury or accident.

Signature(Required)

Date

AFTER-SCHOOL PROGRAM 2025-26 (Middle & Highschool)

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