Aftercare/Afterschool Registration Form

TEACH ACADEMY Aftercare Registration
Scholar's Information

Personal & Health & Contact
Name*

First NameLast Name
Birth Date*

MonthDayYear
Age (upon registration)*
Grade your child is currently in*
Name of School your child currently attends*
Is there anything your child needs to improve on academically, emotionally or socially? Please be specific. (ex. My child was retained, my child is withdrawn or aggresive in school)*
hyperactiveangry/aggressivebossylazysassycalmdistractablewithdrawnmoodydriven(wants to learn everything)Other
What is your child's favorite thing to do?*
List any allergies and dietary restrictions or N/A*
Medications & Frequency*
Has your child been clinically diagnosed with any mental illness?*
Are there any other accomodations your child (ren) may need?*
Parent / Guardian Information

(All correspondence and invoices will be sent to this person)
Name*

First NameLast Name
Email*
example@example.com
Cell Phone*
Format: (000) 000-0000.
Work Phone*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*
Relationship to Scholar*
Emergency Contacts and Authorized Pick Up Person*
Emergency Contacts and Authorized Pick Up Person
Emergency Contacts and Authorized Pick Up Person
Insurance Health Information (Therapy-Group Sessions)
Type of Insurance
Name of primary insurer
Date of Birth of primary insurer
Front of Card

Cancelof
Back of Card

Cancelof
Driver's License

Cancelof
YESNO
YESNO
YESNO
Address of school/pick up location.
Time to be picked up from school/pick up location.
When do you need transportation to begin?
When do you need transportation to end?
YESNO
YESNO
If so, what's the latest time? or Write NA
If so, what's the earliest time? or Write NA
What are the hours you need care?
Debit/Credit CardCashPerformcare FINANCIAL ASSISTANCEDCPP FINANCIAL ASSISTANCEProgram for Parents (full payment)4 C's (Union County residents only)-Program for parentsPartial Payment from parent and partial payment for another agency or person)
YESNO
Terms & Conditions
- Pay the one time application registration fee of $75per child.
- Pay in full weekly even if my child (ren) does not attend the full week $150.
- Payment is due on Monday of each week. I understand if my payment is made Tuesday after 9am , I will be charged a $25 late fee. (If payment is not received by the 2nd week of nonpayment your child would not be able to attend until full payment is received.)
- Allowing my son/daughter to participate in indivdual therapy and or group therapy under Reveal 2 Heal's practicing therapist. (If you do not agree please inform staff)
- Keep my son/daughter home if they are experiencing Covid like symptoms or if they've missed school due to illness.
- Allowing my child(ren) to wear mask at times when it is necessary.
- Pick up my child (ren) on time.
- Allowing children to be transported to and from school for aftercare.
YESNO
How did you hear about us?*
Application Completion Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

TEACH ACADEMY Aftercare Registration

Scholar's Information

Parent / Guardian Information

Insurance Health Information (Therapy-Group Sessions)

Terms & Conditions