2021-2022 LSLA After-Care Registration
All registration and tuition payments are due between the 1st and 5th of each month
SELECT MONTH
*
October 2021
November 2021
December 2021
January 2022
February 2022
March 2022
April 2022
May 2022
Primary Parent/Guardian Name:
*
First Name
Last Name
Primary Parent/Guardian Cell Phone Number:
*
-
Area Code
Phone Number
Primary Parent/Guardian Email:
*
example@example.com
Primary Parent/Guardian Driver's License Number:
*
Secondary Parent/Guardian Name:
First Name
Last Name
Secondary Parent/Guardian Cell Phone Number:
-
Area Code
Phone Number
Secondary Parent/Guardian Email:
example@example.com
Secondary Parent/Guardian Driver's License Number:
Emergency Contact Name:
*
First Name
Last Name
Emergency Contact Cell Phone Number:
*
-
Area Code
Phone Number
Emergency Contact Driver's License Number:
*
Student 1 Name:
*
First Name
Last Name
Student 1 Date of Birth:
*
-
Month
-
Day
Year
Date
Student 1 Grade:
*
K
1
2
3
4
5
Medical Information/Allergies/Special Needs (if any):
*
Registering another child?
*
Yes
No
Student 2 Name:
First Name
Last Name
Student 2 Date of Birth:
-
Month
-
Day
Year
Date
Student 2 Grade:
K
1
2
3
4
5
Student 2 Medical Information/Allergies/Special Needs (if any):
Registering another child?
Yes
No
Student 3 Name:
First Name
Last Name
Student 3 Date of Birth:
-
Month
-
Day
Year
Date
Student 3 Grade:
K
1
2
3
4
5
Student 3 Medical Information/Allergies/Special Needs (if any):
AFTER-SCHOOL CARE OPTIONS
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( X )
Weekly (M-F) Care Per Child Per Month
$
265.00
Quantity
Wednesdays-Only Care Per Child Per Month
$
105.00
Quantity
Debit or Credit Card
Submit
Should be Empty: