2026–2027 After School Program Registration

2026–2027 After School Enrollment

Brain Boosters • CPAS • Titans After School ProgramsComplete one application for all of our after-school locations. Select your preferred program and site during registration.
Parent Information
Parent Name

First NameLast Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Household Information
Lives with
Child Information
Student Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
School & Program Information
Which district will your child attend?
Select School
Grade
School Currently Attending
Daily Arrival & Dismissal
Does your child require transportation provided by our program?
Dismissal Time
Where should we pick up your child? (If we're providing transportation)
How will your child arrive at the program?
How will your child leave the program each day?
Transportation Notes
Emergency Contacts
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Can this person pick up?
Emergency Contact 2 Name

First NameLast Name
Emergency Contact 2 Relationship
Emergency Contact 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Authorized for pickup?
Medication instructions
Medical Information
Does your child have any allergies or medical conditions?
Please explain
Medications taken at school
Doctor Name
Doctor Phone
Please enter a valid phone number.Format: (000) 000-0000.
Hospital Preference
Required Documents
Physical

Cancelof
Custody Papers (if applicable)

Cancelof
IEP/504 (if applicable)

Cancelof
Subsidy Documents (if applicable)

Cancelof
Agreements
Parent Policies & Enrollment Agreement
I understand that a $2 per minute late pickup fee begins immediately after program closing and must be paid before my child may return to the program.
Please review the attached 2026–2027 Parent Policies & Enrollment Agreement before continuing.
I acknowledge that I have read, understand, and agree to the 2026–2027 Parent Policies & Enrollment Agreement, Parent Handbook, and all program policies and procedures. I understand that my electronic signature is legally binding and confirms my agreement to these terms.
Signature
Parent/Guardian Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Electronic Signature