After School Tutorial Program Application
A separate application must be completed on each child. Please indicate your income level.
Form must be completed, and signed.

Community Association for the Welfare of School Children
440 North Foster
Baton Rouge, LA 70806

Start Date: September 5, 2000

Income Guidelines

Household Size Monthly
Low Income		 Monthly
Moderate Income
1 $1,308.33 $2,091.67
2 $1,491.67 $2,387.50
3 $1,679.17 $2,687.50
4 $1,866.67 $2,987.50
5 $2,016.67 $3,225.00
6 $2,166.67 $3,462.50
7 $2,316.67 $3,704.17
8 $2,462.50 $3,941.67
Name Age    DOB (mm/dd/yyyy)
SS#   
Address     City, State
Home Phone (xxx)xxx-xxxx   School     Grade
Parent/Guardian Information
Mother Name Work #     Pager/Cell #
Father Name Work #     Pager/Cell #
Emergency Information
Name     Phone     Physician Name 

Allergies or Other Medical Information 

Names of other children in program 

List person(s) authorized to pick up your child:

Name Home Phone Work Phone

I certify that the above gross income and family size indicated is correct.

Parent Signature

Date

Please download, print and complete the Parent/Guardian Permission & Waiver Form. It should accompany this application.