Creating Community After School Registration

Creating Community After School is committed to providing a safe, nurturing, and engaging after-school environment where children can grow socially, explore their creativity, and build a sense of community where every child feels important and heard.

CCAS begins October 13th and will be held every Tuesday and Thursday on days that school is in session until the end of the school year (to exclude early release days, holidays and other non-school days) from 2:45 to 5:30. The cost is $10 per program day, which is prorated depending on how many program days will be held that month. Families that qualify for scholarships pay 50%. Scholarship application included in this form.

The program will be held at the Reardan Presbyterian Church (non-religious program utilizing the space of the church building). Children will meet at the Elementary Library and we will walk together to the church after a 20-minute study time. Please pick up your child at the Reardan Presbyterian Church (150 W Spokane Ave) by 5:30. An activity bus may be available to transport your child home at the end of the program day and must be coordinated with the bus garage which can be reached at (509)796-4361.

School Attending

Grade Attending

Teacher(s) Name(s)

Are you looking for after school enrichment for your child on Tuesdays, Thursdays, or Both?

First Name

Last Name

Gender

Birth Date

MonthDayYear

Home Phone

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Health Insurance Provider

Health Insurance Member ID

Preferred Hospital in Case of Emergency

Primary Doctors Name

First NameLast Name

Primary Doctors Phone Number

Area CodePhone Number

Full Name

First NameLast Name

Home

Area CodePhone Number

Cell

Area CodePhone Number

Work

Area CodePhone Number

E-mail

Address - Same As Child

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

Full Name

First NameLast Name

Home

Area CodePhone Number

Cell

Area CodePhone Number

Work

Area CodePhone Number

E-mail

Address - Same As Childs

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

Does your child have any allergies?

If yes, please list. Include any food or other allergies.

Does your child have any medical conditions?

If yes, please list.

Does your child take any prescription medications?

If yes, please list.

Is there anything else you would like us to be aware of in regard to your child's health?

Please list ALL people authorized to pick up your child, including full name and phone number. Any person not on this list will not be able to pick up your child regardless of relationship to the child, unless the Program Director has been given PRIOR authorization directly by you.

Please list anyone who is PROHIBITED from picking up your child.

Does your child have any siblings?

If yes, what is/are their name(s) and age(s)?

Are you wishing to enroll any other children into the program? If yes, see below

If wishing to enroll additional children to the program:

First - Complete and Submit this application.

Second - Follow the QR code/application link to generate a new application.

Third - Complete and Submit a new application for each child you are wishing to enroll.

Do you have any additional comments?

Full Name

First NameLast Name

Home

Area CodePhone Number

Cell

Area CodePhone Number

Work

Area CodePhone Number

Full Name

First NameLast Name

Home

Area CodePhone Number

Cell

Area CodePhone Number

Work

Area CodePhone Number

Is your child enrolled in the free or reduced lunch program through the school for the 2026-2027 school year?

If yes, do we have permission to confirm this with the school?

By signing below you confirm that all of the information on this form is true and complete, to the best of your knowledge.

Signature

You will recieve an automated e-mail confirming that we have recieved your completed application. Space is limited and completion of this form is not a guarantee of admission. Our Program Director will contact you via e-mail or phone once your child's admittance to the program is determined.

If you have any questions feel free to reach out to us via e-mail:

ccascontactus@gmail.com

Creating Community After School

After-School Enrichment Program Registration

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Health History

Authorized Pick-up People

Emergency Contact 1 - Other than Parent/Guardian

Emergency Contact 2 - Other than Parent/Guardian

Scholarship Application