IAMBK Program Registration Form 2022-2023

IAMBK Community After School Program (CASP) Registration Form 2022-23

Please fill in the form below.
Child's Name*

PrefixFirst NameLast Name
Child's Birthdate:
Child's Age
Child's Grade in School
Name of Child's School
Child's School System

Auburn CityOpelika CityLee County
Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent's First, Last Name
Phone Number*

Area CodePhone Number
E-mail*
Preferred Method of Contact:

Cell PhoneHome PhoneEmailText
Emergency Contact

First NameLast Name
Emergency Phone #

Area CodePhone Number
List all allergies that your child has:
Select Program(s) in which your child would like to enroll:

Individual and Small Group Tutoring Sessions (ages 6 and up)Teen Counseling Sessions and Life Management (ages 12 and up)Creative DanceParent Cafe (open to ALL parents)MentoringVisual Arts
Preferred Method of Service Delivery:

On-SiteVirtualBoth
Transportation to Program Needed?

YesNo
How did you hear about the program?
Should be Empty:

IAMBK Community After School Program (CASP) Registration Form 2022-23