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
RegularPart-Time
3:00 - 4:00 PM4:00 - 4:30 PM4:30 - 5:00 PM5:00 - 5:30 PM
Authorized Pickup Persons (other than parents/guardians)
I acknowledge that hourly charges apply for after-school care.
I acknowledge that late fees will be applied for late pickups.
Signature of Parent/Guardian*

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Date*

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Date
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