CASH Afterschool Care Registration

Westside Community Center
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
C.A.S.H Afterschool Care Registration
Expected Start Date*

MonthDayYear
Expected Departure Date

MonthDayYear
School Attending
Grade Attending
Are you able to pickup your child from WCC by 6:00PM on your child's designated day? If not, please explain.*
Student Information
First Name*
Last Name*
Gender*

FemaleMale
Birth Date*

MonthDayYear
Home Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information 1
Full Name*

First NameLast Name
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail*
Address - Same As Child*

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information 2
Full Name

First NameLast Name
Home

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
E-mail
Address - Same As Childs

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Other Infomation
Is your child immunized?*

YesNo
Does your child have any allergies?*

YesNo
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?
Does your child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed above?

YesNo
Please list the people authorized to pick up your child.
Does your child have any siblings?*
If yes, what is their age(s)?
Comments
Are you a member of Westside Community Center?
Emergency Contact - Other than Parent/Guardian
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home*

Area CodePhone Number
Cell

Area CodePhone Number
Work

Area CodePhone Number
The cost is $15 per month per child, and some scholarships are available. All registrations are received and reviewed on a first come, first serve basis. Once all open spots are filled, additional submissions will be placed on our waiting list.

Once accepted, you will receive a confirmation email with payment options.
Should be Empty:

Westside Community Center

C.A.S.H Afterschool Care Registration

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation

Emergency Contact - Other than Parent/Guardian