Innovation Hub After-School Program Registration

Innovation Hub After-School Program Registration

Register your child for our after-school program. Please complete all required fields and review each section carefully before submitting.
Student Information

Please provide details about the student being enrolled.
Student Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Grade Level*
School Name*
T-Shirt Size
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Information

Please provide contact details for the primary parent/guardian and an emergency contact.
Primary Parent/Guardian Full Name*

First NameLast Name
Relationship to Student*
Mobile Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Secondary Emergency Contact Name*
Relationship to Student (Emergency Contact)*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Program Details

Select your preferred attendance days and program options.
Homework HelpSportsArtsSTEMMusicOther
Parent PickupAuthorized AdultWalking HomeOther (please specify)
If 'Other', please specify pickup method
Authorized Pickup Persons (names and phone numbers)*
Medical & Special Needs

Let us know about any medical or special needs your child may have.
YesNo
If yes, please describe the allergies
Medical Conditions or Medications (please describe)
Special Needs or Accommodations (please describe)
Permissions & Policies

Review and provide consent for the following permissions and policies.
YesNo
YesNo
Signature & Consent

Please sign below to complete your child's registration.
Parent/Guardian Full Name (for signature)*

First NameLast Name
Signature*

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Date Signed*

MonthDayYear
Date
Should be Empty:

Innovation Hub After-School Program Registration

Student Information

Parent/Guardian Information

Program Details

Medical & Special Needs

Permissions & Policies

Signature & Consent