After School Program Enrollment Form

After School Program Registration
CHILD INFORMATION:
Child Name *

First Name Last Name
Birth Date *

Month Day Year
Grade *
Name of School *
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
MEDICAL INFORMATION
Physician Name

First Name Last Name
Phone Number

Area Code Phone Number
Medical Concerns including emergency medications provided:
Allergies and Reactions:
Authorized People to Pick Up

List anyone who is authorized to pick up your child. ID will be required.
Person 1
Person 2
Person 3
Transportation Options

Choose One Option
How will your child be transported to SGA after school

Bus route from WestSide Van Transport from SL Mason Van Transport from Moulton Branch Private Transportation Request Van Transport from another school (Must have 5 students to consider adding transport option)
Should be Empty:

After School Program Registration