Afterschool Care Registration

2024/2025 Middle Afterschool Student Registration Form
Dear Parents,

Welcome to Epic Kids Learning Academy Middle Afterschool Program at UPA! We believe one of the strongest partnership in a youth's life is between parents,school and the afterschool program in which their child attends. Our program is designed to provide middle school students in 6th-8th grade experiences to enrich and enhance their development and education. The Aftercare Program will begin on August 19, 2024

Hours of Operation

Monday-Friday

3:15pm-6:00pm

Cost: Registration Fee $25.00/$60.00 per week. Also, a free meal and snack is provided.

The Early Learning Coalition can assist eligible parents with the cost of aftercare, you can contact them at (561) 514-3300.

If you have any questions, please contact Mrs. Jenkins at (561) 629-1170 or epickidsla@gmail.com. We look forward to seeing you and your children.

Warm Regards,

Mrs. Jenkins
Grade Attending
Student Information
First Name*
Last Name*
Gender*

FemaleMale
Birth Date*

MonthDayYear
Home Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Health Care #*
Doctors Name*

First NameLast Name
Doctors Phone Number*

Area CodePhone Number
Parent/Guardian Information 1
Full Name*

First NameLast Name
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail*
Address - Same As Child*

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information 2
Full Name

First NameLast Name
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail
Address - Same As Childs

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Other Information
If yes, name and age of friend(s)?
Is your child immunized?*

YesNo
Does your child have any allergies?*

YesNo
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?
Does your child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed above?

YesNo
Please list the people authorized to pick up your child.
Does your child have any siblings?*
If yes, what is their age(s)?
Comments
If yes, which one?
Emergency Contact - Other than Parent/Guardian
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
All registrations are received and reviewed on a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Should be Empty:

2024/2025 Middle Afterschool Student Registration Form

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Information

Emergency Contact - Other than Parent/Guardian