WINTER Jefferson-Houston PTA K-5 After-School Clubs Online Registration Form

After-School Clubs Registration Form

It's almost time for PTA Winter Clubs. Thanks for registering!

Registration Deadline: Friday, December 13, 2024

Siblings: This year you can fill out 1 form for multiple children!

Submission: This form is not complete until you hit "Submit". You'll receive an automated email copy of your responses.

Cost: Each club costs $100.

Scholarships: Scholarships are available; please check the appropriate box to request a scholarship. New option: You can select "Pay What You Can" to request a partial scholarship or "Full Scholarship" to cover the entire cost.

Payment: Do not pay enrollment fees until you receive an enrollment email. Your club choice is not guaranteed as some clubs will be full. For payment options (Venmo, PayPal, check, or credit card), visit www.jeffersonhoustonpta.com/clubs.

Contact: If you do not receive a confirmation or have questions about registration, please email us at clubs.jh.pta@gmail.com.

	Yes	ACPS Bus #	Bus Drop-off Location (Bus Stop or Intersection)
My child has my permission to ride the after-school activity bus on the days enrolled in After-School Clubs.

	Parent/Guardian (provided next in form)	Emergency Contact #2 (provided next in form)	Emergency Contact #3 (provided next in form)
Indicate approved adult(s) to pick up

	Yes	ACPS Bus #	Bus Drop-off Location (Bus Stop or Intersection)
My child has my permission to ride the after-school activity bus on the days enrolled in After-School Clubs.

	Parent/Guardian (provided in form)	Emergency Contact #2 (provided in form)	Emergency Contact #3 (provided in form)
Indicate approved adult(s) to pick up

	Yes	ACPS Bus #	Bus Drop-off Location (Bus Stop or Intersection)
My child has my permission to ride the after-school activity bus on the days enrolled in After-School Clubs.

	Parent/Guardian (provided in form)	Emergency Contact #2 (provided next in form)	Emergency Contact #3 (provided next in form)
Indicate approved adult(s) to pick up

Parent/Guardian Contact Information
Parent/Guardian Name (Emergency Contact #1)*

First NameLast Name
Parent/Guardian Email Address (for club enrollment notification and you will receive a confirmation email when you hit the submit button with a copy of your answers)*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.
Emergency Contact Information
Emergency Contact #2 Name (Someone other than above)*

First NameLast Name
Emergency Contact #2 Phone Number*
Please enter a valid phone number.
Emergency Contact #3 Name (Someone other than above)*

First NameLast Name
Emergency Contact #3 Phone Number*
Please enter a valid phone number.

Behavior Acknowledgement
Parent/Guardian, please read and sign the behavior acknowledgement below.

I understand that in order for the Jefferson-Houston PTA to provide safe, positive After-School Club experiences for all students, unacceptable behavior is not allowed. If a student has difficulties behaving during the Club, he/she will be removed from the Club and placed with a school administrator, and the parent/guardian will be notified. There is no reimbursement if a student must be removed from a Club due to behavior, for absences, or if a Club must be canceled for unforeseen circumstances such as weather, pandemic, or facility issues.
Electronic Signature:
Please type your name
Please provide any additional comments, concerns, or clarifying information below:
Should be Empty:

After-School Clubs Registration Form