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Arts and Enrichment After School Care Notification of Interest Form 2023-2024

This form indicates interest in the after-school care program at Lauri Ann West Community Center for the 2023-2024 School Year. Once completed you will receive a communication on Monday, May 15th 2023 on space availability. Please contact the Programs Manager Jason Fate with any questions!

Please note this form does not guarantee a spot in the program!

Thank you!

Jason Fate

Programs Manager

412-828-8566 x103

jfate@lauriannwestcc.org



Email *
Last Name of Student 1 *
First Name of Student 1 *
Date of Birth of Student 1 *
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Grade Level of Student 1 for 2023-2024 School Year *
School of Student 1 *
Days Interested in Attending Student 1 (You must attend at least 2 days a week in order to participate in our program.) *
Required
Last Name of Student 2
First Name of Student 2
Date of Birth of Student 2
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/
DD
/
YYYY
Grade Level of Student 2 for 2023-2024 School Year
School of Student 2
Days Interested in Attending Student 2 (You must attend at least two days a week in order to participate in our program.)
Primary Parent/Guardian Name (First and Last)  *
Primary Parent/Guardian Contact Phone *
Primary Parent/Guardian Contact Email *
Primary Parent/Guardian Home Address *
Are you interested in our scholarship opportunity? *
Any further questions?
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