Afterschool Program Interest Form!
Parent/Guardian's Name
*
First Name
Last Name
Emergency Contact
*
Name
Phone Number
Parent Email
*
example@example.com
Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please share any details regarding your child that will help make this experience a success!
Child #1
*
First Name
Last Name
Age
*
Child#2
First Name
Last Name
Age
Child#3
First Name
Last Name
Age
Child#4
First Name
Last Name
Please list SchoolDistrict
*
Please Select
Merrillville
Gary
Hobart
East Chicago
Hammond
Lake Station
Crown Point
St. John
Lowell
Griffith
Dyer
Munster
Highland
Valparaiso
Chesterton
Other________________
Submit
Should be Empty: