Before and After School Care Student Registration Form
Child Information
Child's Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Grade
*
School Attending
*
Teacher (if known)
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
City
*
State
*
ZIP
*
Care Needs
Care Needed
*
Before School Only
After School Only
Before & After School
Days Care Is Needed
*
Monday
Tuesday
Wednesday
Thursday
Friday
Anticipated Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian 1 Information
Parent/Guardian 1 Full Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Employer
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2 Information
Parent/Guardian 2 Full Name
First Name
Middle Name
Last Name
Relationship to Child
Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Employer
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Transportation / Bus Information
School Bus Number (if known)
Does the school provide bus transportation to/from Youth Village Restoration Center?
Yes
No
Unsure
Emergency Contacts
Emergency Contact 1 Name
*
First Name
Middle Name
Last Name
Emergency Contact 1 Relationship
*
Emergency Contact 1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 Name
*
First Name
Middle Name
Last Name
Emergency Contact 2 Relationship
*
Emergency Contact 2 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pickup Persons
Authorized Pickup Person 1 Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pickup Person 2 Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical / Health Information
Child's Physician Full Name
First Name
Middle Name
Last Name
Child's Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Does your child have allergies?
*
Yes
No
If yes, please explain the allergies
Does your child have medical, dietary, developmental, behavioral, or other needs?
*
Yes
No
If yes, please explain the needs
Does your child require medication during program hours?
*
Yes
No
Emergency Medical Authorization
Parent/Guardian Initials
*
Parent/Guardian Name (Print)
*
First Name
Last Name
Parent/Guardian Signature
*
Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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