Greggton Afterschool Program

Please fill out the form below to register your child. If you are registering multiple children, a separate form must be completed for each child. All required fields must be completed to ensure registration. For the 2022-2023 school year, the registration fee for each semester is $10 and the program cost is $5 per week per child. If you have any questions, please contact Debbie Moreno at (903) 759-3831.
Today's Date *

Month Day Year
Date
Child's Name *

First Name Last Name
Date of Birth *

Month Day Year
DOB
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
School Attending *
If other, please specify
Grade Level *
Select Grade (K-5)
If other, please specify
We do allow Pre-K & 6th Grade students into our program as long as they have a brother, sister, or other family member who is attending the program between the grades of K-5.
School Teacher's Name *
Please give last name of teacher
Does your child need transportation from school to the GAP? If yes, you are providing consent for your child to be transported and supervised by the operation's licensed workers. Transportation is only provided for Pine Tree schools. *

Yes No
Each Tuesday and Thursday, your child will be given the opportunity to be served two nutritious meals (snack and dinner). These meals are voluntary and free of charge. Please provide any allergies or special diet restrictions that we should be aware of.
Allergies and/or diet restrictions

Parent of Guardian Name *

First Name Last Name
Phone Number (Primary Number) *

Area Code Phone Number
Phone Number (Secondary Number)

Area Code Phone Number
Email *
example@example.com
Address (If different from child's address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name of Emergency Contact #1 *

First Name Last Name
Relationship to Child *
Phone Number for Emergency Contact #1 *

Area Code Phone Number
Address of Emergency Contact #1 *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name of Emergency Contact #2 *

First Name Last Name
Relationship to Child *
Phone Number for Emergency Contact #2 *

Area Code Phone Number
Address of Emergency Contact #2 *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I hereby authorize the following person(s) to pick up the child listed above from the Greggton Afterschool Program. Please list names and phone numbers. *
Authorized Pick-ups
Please use the space below to provide any additional details that we should know in order to ensure proper care of your child.
Additional details
I give consent for my child/children to have their photos taken during program hours to be used for social media/promotional purposes. *

Yes No
I have chosen to not give consent for my child to have their photos taken because of

Privacy Family/custody situations
By providing your e-signature below, you are stating that all of the information listed above is true and complete to the best of your knowledge. *

Signature of Parent or Legal Guardian Clear
Registration fees ($10) and the first week's payment ($5) for the 2022 Fall semester must be paid in full prior to September 6, 2022. You may bring cash or check payments to Greggton United Methodist Church. All following payments are due on the Thursday before the following week. *If payment is not made, transportation will not be provided.
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