After-School Program Enrollment Form

After-School Program Enrollment Form

Please fill out all required fields to enroll your child in the program.
Student Information
Student(s) Name(s)
Mother/Guardian Information
Mother/Guardian Full Name

First NameLast Name
Mother/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mother/Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father/Guardian Information
Father/Guardian Full Name

First NameLast Name
Father/Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Father/Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father/Guardian Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Information
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Allergies and Medical Information
Program Usage
Pickup Time(s)
Authorized Pickup Persons (other than parents/guardians)
Acknowledgment of Hourly Charges
Acknowledgment of Late Fees
Signature of Parent/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: