After School Program Registration

Home After School Program Registration

Child's Name*
First Last
Gender*
- Male
- Female
Date of Birth*
Student's Age*
Please enter a value between 0 and 100.
Student's School*
Name of Parent(s) /Guardian(s)*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone*
Work Phone*
Note: If any of the above information changes, please notify us immediately.
EMERGENCY CONTACT INFORMATION
List two emergency contacts other than those listed above
Contact #1*
Contact #2*

EMERGENCY CONTACT INFORMATION