Team Upward Enrollment Package
Childs Information
1st Child
*
First Name
Last Name
Grade
*
Please Select
Kindergarden
1st
2nd
3rd
4th
5th
School Child Attends
*
Second Child (if applicable)
First Name
Last Name
Grade
Please Select
Kindergarden
1st
2nd
3rd
4th
5th
Enrollment Information
Beginning Date for After School Program
*
-
Month
-
Day
Year
Date
Days attending after school program
Full Week - $100
Partial Week $25 per day
Monday
Tuesday
Wednesday
Thursday
Friday
Other
Parents Information - Mother
Name
*
First Name
Last Name
Employer
*
Cell Number
*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parents Information - Father
Name
*
First Name
Last Name
Employer
*
Cell Number
*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Family Information
Martial Status of Parents
*
Child lives with
*
Please Select
Both Parents
Mother
Father
Grandparents
Step Father
Step Mother
Relative
Other
Are there any social or family circumstances that Team Upward should know about? If yes please describe below.
Drop off / Pick-up / and Release Information
Parents or persons authorized by the parents to pick up or drop off their child at Team Upward After School must escort the child into or out of the center. Other persons to whom Team Upward is authorized to release this child to shall be listed below. Under no circumstances will Team Upward release the child to anyone not identified below or not otherwise known to the staff, without specific authorization from the parent or guardian. The parent or guardian agrees in each instance that he/she will be certain the staff is aware of the child's arrival and departure. *Additions or changes to this list of persons appearing below should be emailed directly to Denzail Jones at denzail.jones@teamupward.org
Authorization Signatures
Our signature below indicates that we have reviewed this agreement and the attached policies and procedures in its entirety and agree to all of the statements and provisions made herein. Items outlined in this agreement may not be changed, waived, discharged or terminated orally, but only by a written agreement that is signed by both the parents and Team Upward. In addition, all information we have provided in this agreement is true and accurate to the best of our knowledge. Any changes in significant information such as addresses, telephone numbers, allergy information, payment information, etc. will be updated in a timely manner.
Mother Signature
*
Date
-
Month
-
Day
Year
Date
Father Signature
*
Date
-
Month
-
Day
Year
Date
The signature above authorizes Team Upward to make tuition charges on the credit card listed below.
Vehicle Emergency Contact and Medical Information
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Parent's/ Guardians Name
*
First Name
Last Name
Cell Number
*
Work Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vehicle Emergency Contact and Medical Information
Submit
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