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First Name *

Last Name

Relationship *

Are you the legal guardian of the child/children you're applying on behalf of? *

Yes

No

Current Address *

City *

State *

Zip Code *

Email Address *

Primary Phone Type *

Cell

Home

Work

Primary Phone Number *

Other Phone Type

Cell

Home

Work

Other Phone Number

Marital Status *

Single/Never Married

Married

Divorced

Widowed

Education Level *

Degree(s) Obtained/Certificate(s) Held

Employment Status *

Full-Time Employee

Part-Time Employee

Entrepreneur/Business Owner

Unemployed/Looking for work

Current Employer

Job Title or Trade

How long have you worked here?

How long at your previous employer?

Yes

No

Which programming? *

Summer Program

Afterschool Program

Both

Why are you interested in your child participating in The Hardy Center After-School Program? *

Participation in The Hardy Center’s After-School programming requires active participation from parents/guardians in order to achieve results. This includes but is not limited to participating in parent/teacher conferences, ensuring The Hardy Center has access to attendance, report card, and testing data from your child’s school, and adhering to rigid attendance policies. Are you willing to partner with us in these and other ways to help your child succeed? *

Yes

No

Do you want to add second parent / guardian details? *

Yes

No

Student 1: First Name *

Student 1: Last Name *

Student 1: Does this student live at an address other than that of the primary parent/guardian? *

Yes

No

Student 1: Address *

Student 1: City *

Student 1: Zip Code *

Student 1: Date of Birth *

Age *

Student 1: Gender *

Male

Female

Student 1: Race/Ethnicity *

Student 1: School *

Student 1: Grade *

Student 1: Has this child ever participated in programming at The Hardy Center? *

Yes

No

Student 1: Which programming?

Summer Program

Afterschool Program

Both

Student 1: Favorite Subject

Student 1: Least Favorite Subject

Student 1: Has this student ever been retained/held back?

Yes

No

Student 1: When/How many times?

Student 1: Does this student have an IEP?

Yes

No

Student 1: Does this student have a 504 Plan?

Yes

No

Student 1: Does this student participate in extracurricular activities (sports, dance, band, clubs/organizations, etc)?

Yes

No

Student 1: Please list extracurricular activities here.

Student 1: During which seasons do the extracurricular activities span?

Spring

Summer

Fall

Winter

Student 1: What day(s) and time(s) do the activities take place?

Student 1: Has this student been diagnosed with any medical conditions or health concerns that may affect their learning or participation in school/after-school program activities?

Yes

No

Student 1: Please explain any medical conditions or health concerns that may affect their learning or participation in school/after-school program activities.

Student 1: Does the student require medication to deal with any of these medical conditions or concerns?

Yes

No

Student 1: Are there any specific behaviors or emotional challenges with this student that concern you?

Yes

No

Student 1: Please explain any specific behaviors or emotional challenges that concern you.

Student 1: Does this student have difficulty managing their emotions or behavior?

Yes

No

Student 1: Please explain the difficulty the student has managing their emotions or behavior.

Student 1: Has this student been diagnosed with any mental health conditions, such as anxiety, depression, or ADHD?

Yes

No

Student 1: Please explain any mental health conditions or diagnosis.

Student 1: Does the student require medication to deal with any of these mental health conditions?

Yes

No

Student 1: Does this student utilize services from mental health professionals or other support services?

Yes

No

Student 1: Please explain the services this student utilizes.

Student 1: Has this student experienced or witnessed any traumatic events such as sexual trauma/violence, domestic violence, or homelessness?

Yes

No

Student 1: Please explain the traumatic events the student has witnessed or experienced.

Student 1: Has this student been assessed or diagnosed with PTSD or other trauma-related disorders?

Yes

No

Student 1: Please explain any assessment or trauma-related disorders the student has been diagnosed with.

Student 1: Has this student experienced changes in sleep patterns, appetite, mood, concentration, or their ability to regulate their emotions?

Yes

No

Student 1: Please explain any of the changes in sleep patterns, appetite, mood, concentration, or abilities to regulate emotions.

Student 1: Is there anything else you'd like us to know about this student (interests, aspirations, etc.)?

**The Hardy Center Afterschool Program Application 2025-2026 (*OPENEDUCAT)**

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

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The Hardy Center Afterschool Program Application 2025-2026 (*OPENEDUCAT)

​When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.​

**The Hardy Center Afterschool Program Application 2025-2026 (*OPENEDUCAT)**

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.