Southside Cultural Arts Center - After School Care Application (2023-24) 2023-24 After School Care Application Please fill out all information.Â
Which site will your child attend?
- Select - Dream Center Optimist and Arts Academy Dream Center at Southside Cultural Arts/Ft. Lauderdale Dream Center at Holiday Park/Ft. Lauderdale
Will your child require transportation assistance?
- Select - YES NO
What grade is your child in for the 23-24 school year
- Select - Pre K K 1 2 3 4 5
What is the sex of your child?
- Select - Female Male
Is your child proficient in English
- Select - YES NO
Other languages spoken in your home
- Select - Haitian Creole Spanish Other
Which race/ethnicity best describes your child?
- Select - American Indian or Alaskan Native Asian / Pacific Islander Black or African American Haitian Hispanic White / Caucasian Other
Does the child have health insurance?
We want to help your child in the best way possible and grant the best experience. Please tell us the way your child communicates. Check all that apply
Speaks and is easily understood Speaks but is difficult to understand Uses communication devices like pictures or a board Uses gestures or expressions like pointing, pulling, smiling, frowning or blinking Uses sign language Using signs that are not words like laughing or grunting
What, if any, help does you child receive at this time? Check all that apply
Behavioral therapy or services Counseling or emotional concerns Daily medication (not including vitamins) Occupational Therapy Physical Therapy Special Educational Services in school Speech/Language Therapy None of the above
What conditions does your child have that are expected to last for a year or more? Check all that apply
Autism spectrum disorder Problems with aggression or temper Problems with attention or hyper activity (ADHD) Developmental delay (only if under age 5) Intellectual/Developmental disability (if over age 5) Hearing impairment or deaf Learning disability (school age) Medical condition or illness Physical disability or impairment Problems with depression or anxiety Speech or Language condition Vision impairment or blind None of the above
Do any of the conditions marked above make it harder for your child to do things that other children can't do?
- Select - YES NO
Section Break Some description about this section
To support your child, what are of assistance might your child need help in
No extra help is needed Holding a pencil, crayon, etc. Sports or physical activities like running, or other gross motor tasks Managing feelings and behavior Academic learning or reading activities Adapting activities to take into account a visual or hearing impairment Using assistive devices like wheelchair, crutches, braces, or walker Personal services like help with feeding or toileting
Other than the child's Parents, who is permitted to pick up the child? List names
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