Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Days of week after school care is needed:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Parent/Guardian Completing Form
*
First Name
Last Name
Parent/Guardian Cell Phone Number
*
Parent/Guardian Email
*
Your Relationship to Child
*
Mother
Father
Legal Guardian
Other
Child's Father's Name
*
First Name
Last Name
Child's Mother's Name
*
First Name
Last Name
Marital Status of Child's Parents
*
Single
Engaged
Married to child's mother/father
Married to child's stepmother/stepfather
Separated
Divorced
One or both parents are deceased
Other
Date you would like to start After School Care Program:
*
-
Month
-
Day
Year
August 8th, 2024 is earliest date accepted
Pick up time from school:
*
PM
AM/PM Option
Submit
Should be Empty: