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.
Program Options*

Homework HelpSportsArtsSTEMMusicOther
Pickup Method*

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.
Does your child have any allergies?*

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.
Do you give permission for your child to be photographed or recorded during program activities?*

YesNo
Do you authorize staff to seek emergency medical treatment for your child if necessary?*

YesNo
Signature & Consent

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

First NameLast Name
Signature*
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