Day Treatment After School Program Registration Form

Day Treatment After School Program Registration Form

Please fill out this form to register your child for our After School program. Program begins Monday September 28th - Thursday December 10th, 2026 and meets from 4 - 7PM on Mondays, Tuesdays, and Thursdays ONLY. ***A separate form is required for each child***
Child's Name

First NameLast Name
Gender

Other
Age
Parent/Guardian Name

First NameLast Name
Relationship to Child

Other
Is transportation needed?
Pick-Up Address for Child (Can be home or school, please include the school name if child is being picked up from school)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Address (for drop-off)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Does your child have any allergies, dietary restrictions, or health conditions we should be aware of?
THANK YOU for registering your child!
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