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After School Online Registration Form
After School Program Online Registration Form

Fees:

Select Your Schedule:
Monday, Tuesday, Thursday, Friday - $8.00/dayCheck the days you want your child to regularly attend:
Wednesday - $13.00/day  Mon   Tue    Wed   Thur    Friday 
Two-Day Special Rate (includes Wed.) - $18.00 
Three-Day Special Rate (includes Wed.) - $24.00Check the days you want your child to be a "Drop In":
Four-Day Special Rate (includes Wed.) - $36.00  Mon    Tue    Wed    Thur    Friday 
Five-Day Special Rate (includes Wed.) - $42.00 

 

Student's Last Name: 

Student's First Name: 

Parent / Guardian Last Name: 

Parent / Guardian First Name: 

Date of Birth: 

Age: 

Grade: 

Home Phone Number: 

Cell Phone Number: 

Email: 

Parent / Guardian Work Phone Number: 

Emergency Phone Number: 

Physician's Name: 

Physician's Phone Number: 

Physician's Address: 

Does your child take medication? 

Type of Medication: 

Does your child have allergies? 

Type of Allergies: 

Does your child have dietary needs? 

Specify the needs: 

Any additional needs that the staff should be aware of? 

Please Explain: 

 

Emergency Pick-Up Information (If you cannot be reached)

1.

Name:

Phone: 

Relationship: 

2.

Name: 

Phone: 

Relationship: 

 

 

Please list people your child may be released to: 

Please list people your child MAY NOT be released to:

 

 

EMERGENCY PERMISSION

I give permission for my child,  , to participate in all activities that are part of the Erving After School Academy.  I give permission for the After School Academy staff to attend to any emergency that may occur during the session and seek medical attention, if necessary.  I understand that if I cannot be reached, the staff will contact one of the emergency names I have listed.

Parent / Guardian Electronic Signature:    Date: 

 By checking this box, you acknowledge this Electronic Signature is your acceptance and agreement as if actually signed by you in writing for this Permission Form.

 


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