After Care Program Enrollment
A separate form is required for each student enrolling in the program.
Start Date
*
-
Month
-
Day
Year
Date
Type of enrollment
*
Please Select
Full time (3:45-6:00) $240/month
Part time (3:45-5:00) $140/month
Name
*
First Name
Last Name
Date of birth:
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Name
*
First Name
Last Name
Father's Name
*
First Name
Last Name
Mother's Cell:
*
Father's Cell:
*
Mother's Work Number:
*
Father's Work Number:
*
Mother's email
*
example@example.com
Father's email
*
example@example.com
Authorization for Emergency Medical Treatment
I give consent for FCA East Lewisville After Care Program to secure any and all necessary emergency medical care for my child.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Allergy or other Health concerns:
Please list any health concerns that staff should be aware of.
Permission to Release My Child To:
Primary person picking up:
*
Relation to child
*
All other individuals listed below MUST show proof of identification:
Please type name and relation to child.
Save
Continue
Continue
Should be Empty: