After School Program Registration Form

After School Program
After School Program Application
Information of Child
Name

First NameLast Name
Birth Date

MonthDayYear
Date
M.I.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your child have a sibling that will also be participating?

YesNo
Gender

FemaleMale
Information of Parent
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Place of Work
Emergency Contact 1
In the event of an emergency, please contact:
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Place of Work
Other people authorized to pick up child from school
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Place of Work
Medical Information
Preferred hospital
Are there any behavioral or special issues we need to be aware of for your child in order to meet their individual needs?
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
Photo/Video Release: I grant permission for Iuka Sports Academy to use photographs or video recordings of my child for promotional purposes:

YesNo
Should be Empty:

After School Program