2026- 2027 WHJESP Before & After School Program Enrollment Form

AM and PM School Program Enrollment Form

2026-2027
Please download the Parental Handbook.

Download the Parental Handbook
Parent's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Phone Number

Area CodePhone Number
Parent's Email
Student's Full Name

Last NameFirst Name
Grade in Sept. 2026
Gender
Date of Birth

MonthDayYear
Date
Demographics (info used for demographic analysis only)
Primary Language
Emergency Contact 1

First NameLast Name
Phone Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact 2

First NameLast Name
Phone Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Email
example@example.com
Student's Name

First NameLast Name
Grade in Sept. 2025
Gender
Date of Birth

MonthDayYear
Date
Demographics (info used for demographic analysis only)
Primary Language
Student's Name

First NameLast Name
Grade in Sept. 2025
Gender
Date of Birth

MonthDayYear
Date
Demographics (info used for demographic analysis only)
Primary Language
Student's Name

First NameLast Name
Grade in Sept. 2025
Gender
Date of Birth

MonthDayYear
Date
Demographics (info used for demographic analysis only)
Primary Language
Does any of the children that you are enrolling, have an IEP?
Does Your Child Have An 504 Plan? Please Indicate Which Child
Effective date for enrollment

MonthDayYear
Please indicate the month and day that this agreement is to take effect. For example, if you will be using the After School Program from the first day of school, enter 09-__-2026.
Indicate the day(s) that you anticipate utilizing the AM School Program (If you don't want AM program please select NO AM Program):
Indicate the day(s) that you anticipate utilizing the PM School Program (If you don't want PM program please select NO PM Program):
My child will take the AM School Bus from Primary to Intermediate:
My child will take the PM School Bus from Intermediate to Primary:
Please note any known allergies or medication (If no, please put N/A)
Does it require an EpiPen? If Yes, Please specify student
Diagnosed behavioral or emotional issue (If no, please put N/A)?
If YES, please Specify student and condition
Diagnosed chronic Illness (If no, please put N/A)
If YES, please Specify student and condition
What helps your child regain a sense of calm when they are having a difficult moment?
Is there anything you'd like to share about your child that will help them thrive while in our care? (Examples: interests, routines, learning & communication needs, motivators, family traditions or any other information you'd like staff to know.)
Please specify each person, including the name of parents, who has permission to pick up your child from the AM and PM School Program.
Authorized Person 1:

First NameLast Name
Relationship
Phone Number 1:

Area CodePhone Number
Authorized Person 2:

First NameLast Name
Relationship
Phone Number 2:

Area CodePhone Number
Authorized Person 3:

First NameLast Name
Relationship
Phone Number 3:

Area CodePhone Number
Child Care Payment Assistance

Approval Letter is required prior to start date.
Will you be using a child care subsidy to help pay for your child's before- and/or after-school care?

Other
If you selected "Yes," please complete the following:
Case Number (if available)
Who is financially responsible for making the monthly program payments?
I acknowledge that I am financially responsible for all tuition and program fees associated with my child's enrollment in the After-School Program.I understand that if I have applied for a child care subsidy, I remain responsible for all program payments until my subsidy application has been approved and the program has begun receiving payments on my behalf.I further understand that if my child care subsidy application is denied, delayed, expires, or terminated, I am responsible for paying any remaining balance in accordance with the After-School Program's payment policies.I acknowledge that I have read, understand, and agree to these financial responsibilities.
Photo Release Form

Dear Parent/Guardian, We, at the Willie Hutch Jones Educational and Sports Program, will be taking photos of participants during their activities within the premises. In this regard, we seek your consent for the publishing or use of photos which your child may be included. The photos will be used for bulletin boards, marketing or advertising, and/or marketing updates posted via the facebook page, and website. Should you decide to take back your authorization later on, you may do so by writing to us. For protection of the privacy of the child, we guarantee that names will not be included.
Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the {Organization} and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Informed Consent and Acknowledgement As the legal guardian, I grant my child permission to participate in the 2026-2027 Willie "Hutch" Jones Educational & Sports Program (WHJESP) and confirm the accuracy of the information provided above. Furthermore, I release WHJESP, its employees, contractors, and volunteers from all responsibility or liability and hold them harmless for any incidents or injuries that may occur before, during, or after the program. This waiver also releases WHJESP and its sponsors from any lawsuits or claims arising from accidents or injuries related to this event.
REGISTRATION FEE: Please pay this one-time non-refundable registration fee per child.

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