2024-2025 Teen After-School Pre-registration Form

2024-2025 Teen After-School Program

PRE-REGISTRATION FORM
Completing this form DOES NOT guarantee your child a spot in the after-school program. This form allows you to express interest in your child being considered for the program.
Please complete this form in its entirety.
CHILD'S INFORMATION
Child's Name*

First NameLast Name
Date of Birth*
Ex. 11/21/2014
Age*
Gender*
Race*
School*
Grade Level for 2024-2025 School Year *
Does your child receive any of the following services or participate in any of the following programs? Please check all that apply.

Free/reduced lunchIndividualized Education Plan (IEP)504 (accommodation)Sessions with school or private counselorSpeech coachMedicaidOther
If you checked "other," please explain:
PRIMARY PARENT/GUARDIAN/CAREGIVER INFORMATION
Name*

First NameLast Name
Relation to Child*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you reside in a Winder Housing Authority property?*

YesNo
Primary Phone Number*
Please enter a valid phone number.
Email*
example@example.com
HOUSEHOLD INFORMATION
Number of Adults in the Household*
Number of Children Younger than Age 18 in the Household*
Annual Household Income Range*
Ex. $18,000-$20,000
Does your household receive any of the following benefits or assistance? Please check all that apply.

SNAP/Food StampsMedicaidSupplemental Security Income (SSI)Social Security Disability Insurance (SSDI)TANFHousing assistanceOther
If you checked "other," please explain:
Please be prepared to provide documentation of benefits, assistance, and income upon request should your child become enrolled in the after-school program.
Should be Empty:

2024-2025 Teen After-School Program

CHILD'S INFORMATION

PRIMARY PARENT/GUARDIAN/CAREGIVER INFORMATION

HOUSEHOLD INFORMATION