After-School Care
Registration Form
Child's Full Name:
First Name
Last Name
Nickname/Preferred Name:
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Grade Level:
What type of educational format is your child currently apart of? (Homeschooled, micro-school, public school, unschooling etc.)
Parent/Guardian Full Name:
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Authorized Pick-Up:
List all of the people who are authorized to pick-up your child: (Please include their full legal name, their relationship to the child and phone number)
Is anyone NOT allowed to pick-up your child? Please explain.
Day(s) your child will be attending after-school care:
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Typical arrival time:
Typical pick-up time:
Start date:
Frequency of attendance:
Ongoing enrollment
Drop-in
Other
Medical Information:
Allergies?
Medical Conditions?
Medications? (If applicable during After-Care hours)
Primary Care Physician:
First Name
Last Name
Primary Care Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
In the event of an emergency, I authorize the program facilitator to obtain medical treatment for my child if I cannot be reached immediately. I understand every effort will be made to contact me first and I accept responsibility for any medical costs.
I agree
Signature
Submit
Should be Empty: