AFTER SCHOOL PROGRAM APPLICATION

AFTER SCHOOL PROGRAM APPLICATION

MEDGAR AND ANGELA SCOTT COMMUNITY LIFE CENTER
Student's Information
Student's Name*

First Name Last Name
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
DOB (mm/dd/yyyy)*
Gender of Student*

FemaleMale
Parent or Guardian's Name - 1*

First Name Last Name
Relationship to Child*

MotherFatherOther
Parent or Guardian Name - 2

First Name Last Name
Relationship to Child

MotherFatherOther
Best Day Time Phone *
Alternate Phone Number*
Please enter a valid phone number.
Parent or Guardian E-Mail*
example@example.com
Child Release Authorization

PERSONS AUTHORIZED TO PICK UP CHILD FROM FACILITY OTHER THAN PARENTS LISTED
Authorized Person*

First Name Last Name
Phone Number
Please enter a valid phone number.
Relationship to Child*
Autorized Person*

First Name Last Name
Phone Number*
Please enter a valid phone number.
Relationship to Child*
School and Interests Information
School Name and Grade for 2022-23 School Year*
Subject area in which student may need the most assistance (choose all that apply).*

Reading/Language ArtsHistory/Social StudiesSciencesMathOther
Subject area in which student is most interested (choose all that apply).*

Reading/Language ArtsHistory/Social StudiesSciencesMathOther
Please list any extra curricular activities that are of interest to your child.
Please list any special talents that your child may have.
Program Requirements:

Students must exhibit the following characteristics during this program.
- Good Work Ethic
- Self-Motivation
- Organizational Skills
- Positive Attitude
- Collaboration and Cooperation with Others
To assist in creating a happy and healthy learning environment for all students, and to ensure that the best care is provided to your child, please list any allergies, injuries, medical conditions that may limit certain foods or physical activity.*
By completing and signing this application, I acknowledge and agree to the program requirements, terms, and conditions. I acknowledge that pictures of students and program activities will be included on our website and various printed materials for promotional purposes.

*I acknowledge that the tuition fee of $65.00/week is due by Monday of the current week.
Parent or Guardian Signature*

Clear
Date*

MonthDay Year
Date
Should be Empty:

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AFTER SCHOOL PROGRAM APPLICATION

Student's Information

Child Release Authorization

School and Interests Information