After School Registration Form

At Mr. Robert's After School Program

Fill out the form carefully for registration
Student's Name *

First Name Last Name
School Name *
Teacher Name *
Grade *
Room Number *
i.e A or B
Birth Date *

Month Day Year
Gender
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
1. Parent's Name *
Please list the parent who will be the main point of contact.
Parent's Email *
Parent's Phone Number *
Relationship to Student *
2. Parent's Name *
Parent's Email *
Parent's Phone Number *
Relationship to Student *
Emergency Contact's Name *
Please list an emergency contact other than the parent's listed above.
Emergency Contact's Name *
Please list an emergency contact other than the parent's listed above.
Emergency Contact's Phone Number *
Emergency Contact's Phone Number *
Medical Information
Physician Name *
Physician Phone Number *
Medical Concerns *
Authorization for Student Pick Up

Other than Parental Guardians
Full Name:
Please list name as it is listed on driver's license
Phone Number:
Full Name:
Please list name as it is listed on driver's license
Phone Number:
Full Name:
Please list name as it is listed on driver's license
Phone Number:
Please Check Days Your Child Will Attend: *

Monday Tuesday Wednesday Thursday Friday
Signature *

Clear
Date *

Month Day Year
Date
Photo Release
I give permission to The At Mr. Robert's staff to publist any photos or videos that may be taken of my child for At Mr. Robert's use for our personal Facebook, Instagram, and Tik Tok Pages.
Signature

Clear
Date

Month Day Year
Date
Health History
Date of Birth: *

Month Day Year
Age: *
Allergies: Please list ALL known medication, food and other allergies
Signature *

Clear
Date *

Month Day Year
Should be Empty:

At Mr. Robert's After School Program

Medical Information

Authorization for Student Pick Up

Photo Release

Health History