TEACH ACADEMY Aftercare Registration
Scholar's Information
Personal & Health & Contact
Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
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December
Month
Please select a day
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Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
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2015
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2012
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Year
Age (upon registration)
*
Please Select
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18+
Grade your child is currently in
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
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 My child was retained, my child is withdrawn or aggresive in school)
*
How would you describe your child's temperament?
hyperactive
angry/aggressive
bossy
lazy
sassy
calm
distractable
withdrawn
moody
driven(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 Name
Last Name
Email
*
example@example.com
Cell Phone
*
Format: (000) 000-0000.
Work Phone
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / 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
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back of Card
Browse Files
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Choose a file
Cancel
of
Driver's License
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What are the hours you need care?
How will you pay?:
*
Debit/Credit Card
Cash
Performcare FINANCIAL ASSISTANCE
DCPP FINANCIAL ASSISTANCE
Program for Parents (full payment)
4 C's (Union County residents only)-Program for parents
Partial Payment from parent and partial payment for another agency or person)
I have an open case with DCPP.
YES
NO
Terms & Conditions
Pay the one time application registration fee of $$125 per child.
Pay in full weekly even if my child (ren) does not attend the full week.
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 or pay the one dollar per minute late fee.
Allowing children to be transported to and from school for aftercare.
OPTIONAL: I am ready to pay the registration fee to secure my child(ren) seat. Please send the payment link to my cell phone number above.
YES
NO
How did you hear about us?
*
Application Completion Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit
Should be Empty: