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S.T.A.R.S After School Program Registration Form
| 740 Canal St. Merced Ca, 95341 | 209-580-7061 | Serenitystaff21@gmail.com |
Serenity S.T.A.R.S (Strengthen, Transform, Affirm, Restore, and Support) program provides FREE after school tutoring services for students in K-8th grade.
Childs Information
Name
First Name
Last Name
Date of Birth
Age
Gender
Ethnicity
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
School
Grade
Allergies / Medical Conditions
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a sibling enrolled in S.T.A.R.S After School Program?
Please Select
Yes
No
If Yes Name
Back
Next
Parent / Guardian Information
Name
First Name
Last Name
Legal Custody
Please Select
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Email
example@example.com
Parent / Guardian Information
Name
First Name
Last Name
Legal Custody
Please Select
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Email
example@example.com
Back
Next
Authorized Pickup and Emergency Contact (Must be 18 or over)
Only people listed on the authorized pick-up list will be allowed to sign your child out of the program. Any changes must be made IN PERSON. In case of emergency the Parent/Guardian will be contacted first. If Parent/Guardian cannot be reached, we will then call the people listed below in the order listed.
Name / Relationship
Phone
Name / Relationship
Phone
Name / Relationship
Phone
PHOTO AND VIDEO CONSENT ASSIGNMENT AND RELEASE
In order to participate in the STARS After School Program, parents/guardians give permission for their child to be photographed or videotaped while attending the program. Pictures and videos captured may be used for promotion of the program, which could include being shared on program materials, social media, or the program's website.
Parent / Guardian Name
First Name
Last Name
Parent / Guardian Name
First Name
Last Name
Signature
*
Signature
Continue
Continue
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