After-School Program Enrollment Form

After-School Program Enrollment Form
Student Name

First NameLast Name
Student Medicaid Number
Upload Medicaid Card

Cancelof
Student Birth Date

MonthDayYear
Date
School Name and Grade Level 2025-26
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Should be Empty: