Bright Futures Scholar Application

Welcome to PCYC’s Bright Futures! The following form will gather the information required to begin the registration process. Please note that completing this form does not guarantee enrollment.

This application process will take about 10-15 minutes to complete. Please complete an application for each scholar that you would like to enroll.

Please read all instructions and proceed through all sections of the form. Be sure to fill out the entire form. ‘Electronic Signature’ is required. You must then press the submit button to complete the form. Application is valid for one (1) year.

If you have any questions, please contact Jaleeza Smith-Breedlove (612) 643-2096.

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Scholar Information

Parent / Caregiver Information

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Parent / Caregiver Information Continued

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 Emergency Contact (to call if parent / caregiver cannot be reached)

In addition to those listed above, please list below all other authorized adults who are allowed to sign your scholar out of our program. Note: Bright Futures will not release scholars to individuals who are not listed on this form without parental consent.

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Health Information & History
The following information must be completed by the parent / caregiver. The intent of this information is to give staff the background information they need in order to provide appropriate care. Please provide complete information so we’ll be aware of all your scholar’s needs.
List all medications by prescription name, purpose, dose and how often it's taken for each medication that your scholar takes every day or as needed. If medication needs to be administered during program hours, please contact the program director.
Authorization of Consent for Treatment of a Minor
Insert your full name here.
Insert scholar's name below.

I do hereby give my consent to Bright Futures for said scholar to receive medical or surgical aid as may be deemed necessary and practical by a suitably licensed or recognized physician or surgeon, in case of an emergency when caregivers cannot be reached. Consent is also given for Bright Futures to transport said scholar for emergency medical treatment if caregivers cannot be reached. This authorization shall remain effective until the end of my scholar’s participation in Bright Futures.

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Parent Acknowledgement
Please initial the box below to show that you have read and acknowledge these statements:
  • By enrolling my scholar, I am giving Bright Futures and/or parties designated by Bright Futures permission to record audio and / or images (still or moving) of my scholar and to use such media at Bright Futures’s sole discretion.
  • By enrolling my scholar, I am giving permission for my scholar to attend field trips or excursions away from Bright Futures’s main facility, under proper supervision, and including transportation provided or arranged by Bright Futures.
  • By enrolling my scholar, I understand that Bright Futures and / or collaborating partners collect data to be used for the purposes of evaluating the program and for ongoing improvement. I further understand that my scholar’s data will be kept confidential.
  • By enrolling my scholar, I am giving Bright Futures permission to request and receive my scholar’s written and verbal education and behavioral data including but not limited to IEP and standardized testing results from teachers, social workers and school administrators.