IMAGINE CHANCELLOR
BEFORE CARE & AFTER CARE PROGRAM REGISTRATION APPLICATION
Program:
*
June Before & After Care
June Before Care Only
June After Care Only
June Occasional (daily)
July Before & After Care
July Before Care Only
July After Care Only
July Occasional (daily)
Student Information
1st Child:
First Name
*
Last Name
*
Gender
*
Female
Male
Grade
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
Medical/Allergies:
*
Student Information
2nd Child (if applicable):
First Name
Last Name
Gender
Female
Male
Grade
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
Medical/Allergies:
Student Information
3rd Child (if applicable):
First Name
Last Name
Gender
Female
Male
Grade
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
Medical/Allergies:
Student Information
4th Child (if applicable):
First Name
Last Name
Gender
Female
Male
Grade
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
Medical/Allergies:
Parent/Guardian Information 1
Full Name
*
First Name
Last Name
Cell
*
-
Area Code
Phone Number
Work
-
Area Code
Phone Number
E-mail
*
Parent/Guardian Information 2
Full Name
First Name
Last Name
Cell
-
Area Code
Phone Number
Work
-
Area Code
Phone Number
E-mail
Emergency Contact - Other than Parent/Guardian
Full Name
*
First Name
Last Name
Cell
*
-
Area Code
Phone Number
Please list ALL the people authorized to pick up your child.
*
Your child will NOT be released to anyone who is not listed above
Parent Signature
*
First Name
Last Name
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: