ASC Registration

Please make sure you have reviewed the After School Care Handbook before completing this form.

Registration Deadline is August 22nd, by 6pm.

After School Care Hours: 3:00pm - 5:30pm

After School Care Location: Youth Room

If you sign-up for an After School Care Plan, you will be billed in advance at the beginning of each month.

If you choose the drop in plan, you will be billed at the end of each month for the days your child(ren) attended ASC.

All ASC payments must be current for your child(ren) to continue with the program.

We understand emergencies come up and you may need to send your child to ASC unexpectedly during the school year. We offer each family a one time unregistered use of the program. You will still be charged the Drop In Care rate for the time your child is in the program. However, the second time you use the ASC program unregistered, you will be charged the late registration fee of $40.

Please Choose the Type of Care Needed:*

Please Choose the Number of Days Needed:*

Child's Name:*

First NameLast Name

Child's Grade:*

2nd Child's Name:

First NameLast Name

2nd Child's Grade:

3rd Child's Name:

First NameLast Name

3rd Child's Grade:

4th Child's Name:

First NameLast Name

4th Child's Grade:

Parent/Guardian Name:*

First NameLast Name

Parent/Guardian Email:*

example@example.com

Parent/Guardian Cell Phone:*

Area CodePhone Number

Parent/Guardian Home Phone:*

Area CodePhone Number

Parent/Guardian Work Phone:*

Area CodePhone Number

Parent/Guardian Status:*

Parent/Guardian Authorized to Pick Up Child(ren); please include contact number(s) for spouse if listed.*

Please list other person(s) authorized to pick up; include contact phone number(s) for each (Must be in FACTS account):*

Emergency Information
Please list any medical conditions, allergies, problems or special needs that your child(ren) may have and emergency contacts (other than authorized persons) that we may call in any emergency.

Please list any medical conditions, allergies, problems or special needs that your child(ren) may have and emergency contacts (other than authorized persons) that we may call in any emergency.

Person(s) to contact in case of emergency if you cannot be reached; please include phone number(s):*

Signature:

By clicking here, I agree that staff may authorize a physician to provide emergency care in the event that I cannot be contacted.

Name of Person Completing and Signing this form:*

First NameLast Name