LEAPSTART 2020-21 SCHOOL YEAR PROGRAM REGISTRATION FORM

2020-21 LEAPSTART SCHOOL YEAR PROGRAM

(ONLINE & ON-SITE)

ENROLLMENT FORM

Existing Student? *

Existing Student Name *

Child's Information

First Name *

Last Name *

DOB *

Date

Gender *

School Name *

Grade *

Home Street Address *

City *

State *

Zip Code *

Referred By

Parent"s Information

Mother"s Name *

Mom's E-mail *

example@example.com

Mom's Phone *

Father"s Name *

Dad's E-mail *

Dad's Phone *

Dad's Employer *

Mom's Employer *

Emergency Work Phone(s)

For onsite program, Allergies or other medical conditions

2020-21 SCHOOL YEAR PROGRAMS

SEATS ARE LIMITED DUE TO SOCIAL DISTANCING MEASURES IN PLACE

*NEW* ONLINE HOMEWORK HELP & ACTIVITIES PROGRAM, 2 HRS A DAY

CHOOSE HOURS

2:30PM - 4:30PM 3:00PM - 5:00PM

*NEW* ON-SITE SCHOOL SESSION ASSISTANCE, HOMEWORK & ENRICHMENT PROGRAM, 8:00AM - 6:00PM, LUNCH N SNACKS PROVIDED

*NEW* ON-SITE SCHOOL SESSION ASSISTANCE & HOMEWORK HELP PROGRAM, 8:00AM - 2:00PM, LUNCH N SNACKS PROVIDED

*NEW* ON-SITE AFTER SCHOOL & ENRICHMENT PROGRAM, 2:00PM - 6:00PM, SNACKS PROVIDED, OUTDOOR ACTIVITES INCLUDED

*NEW* ON-SITE OUTDOOR WEEKEND PROGRAM FOR SOCIAL & PHYSICAL ACTIVITY, SNACKS PROVIDED

CHOOSE HOURS

10:00AM - 12:00PM 4:00PM - 6:00PM

CHOOSE START DATE *

Date

I understand and agree that a non-refundable registration fee of $75 shall secure a space for my child until the requested start date.

REGISTRATION FEE *

Calculated Total *

REGISTRATION FEE *

USD Leapstart 2020-21 School Year Program Fee

Pay by Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code