LAUNCH Kenmore After School Program 2025-2026
Email: taylorbuchanan@firstglance.org with any questions. We transport students from school to First Glance each day. The cost is $5 per student per day. Payments are due by the end of each week. Pick up time is 4:45-5pm.
Student Information
Student Name
*
Student Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
School
*
Pfeiffer
Rimer
Sam Salem
Grade
*
K
1st
2nd
3rd
4th
5th
Parent Information
Parent Name
*
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Other people authorized to pick up student from LAUNCH Kenmore
Name & Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name & Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical information
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
*
General Permission
General Permission: I do hereby, for myself, my heirs, executors and administrators, waive and release all right and claim for damages I may have against First Glance Student Center. I am the legal guardian of the student(s) named below and hereby give my permission for the named student(s) to participate in the First Glance activities both on-site and off-site. I attest that I have full knowledge of the risks involved, and if I am unable to be reached, authorize that First Glance’s leadership use their best judgment in acting on behalf of my child, including the administration of emergency medical treatment by available medical personnel. I will hold the medical personnel, the leaders and First Glance harmless of their action in such a situation. By typing my name in the box, I agree to the terms above.
*
Submit
Should be Empty: