Rogers After-School Program Sign Up
Student Full Name
*
First Name
Middle Name
Last Name
Preferred Pronouns
Grade Level
*
Please Select
5th
6th
7th
8th
9th
10th
11th
12th
for Incoming A.Y. '12-'13
Student Email
example@example.com
Student Phone Number
Format: (000) 000-0000.
School Attending
*
The Rogers Program is open Tuesday-Wednesday, 2:15-5:00 PM. Please select the day(s) that will be attended most consistently.
*
Tuesday
Wednesday
Please select the planned method of transportation for the student to and from the program.
*
Walk
Bus
Parent or Guardian Drop Off/Pick Up
Interested in Receiving Transportation
Other or Combination
If other, please explain.
Parent or Legal Guardian Name
*
First Name
Last Name
Secondary Parent or Legal Guardian Name (optional)
First Name
Last Name
Parent or Legal Guardian Email
*
example@example.com
Secondary Parent or Legal Guardian Email (optional)
example@example.com
Emergency Contact
*
First Name
Last Name
Relationship
*
ex. Father, Mother, etc.
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I understand and agree that my student will be picked up no later than 5:00 PM from the after-school program. If an unforeseen event delays this timeline, I will contact Thumbs Up Staff.
*
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