After-School Registration Form
Student Information
Name
First Name
Last Name
Grade
School Currently Attending
Gender
Please Select
Male
Female
N/A
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Student has an IEP?
Yes
No
Parent(s)/Guardian(s) Information
Please list in order of whom to contact first
*
Emergency Information
Name
First Name
Last Name
Relationship
Phone Number
Format: (000) 000-0000.
Health Information
Family Doctor
First Name
Last Name
Clinic
Phone Number
Format: (000) 000-0000.
Please let us know if this child have any allergies
*
List medications if this child is currently taking
*
Have this child had any serious illnesses or operations?
Yes
No
If yes, please describe
Can this child take part in regular physical activities?
Yes
No
Do you want to indicate any related information?
Date of Registration
-
Month
-
Day
Year
Date
Back
Next
Person(s) allowed for Pick-up
Rows
Name
Phone Number
Relationship
Pick-Up Person 1
Pick-Up Person 2
Registration Fee
*
prev
next
( X )
USD
Description
Credit Card
Submit
Should be Empty: