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After School Registration Form
When: Tuesday - Friday 2:30pm-6:00pm
Where: 3845 Raleigh Millington Rd. Memphis, TN 38128
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Parent Name *
DOB *
Phone Number *
Email Address *
Address *
City *
State *
Zip Code *
How many children do you have in your household 18 and under? *
Name of Child #1 *
Child #1 DOB *
Child #1 Gender *
Child #1 School Attending  *
Child #1 Grade Level *
Child #2 Name *
Child #2 DOB *
Child #2 Gender *
Child #2 School Attending *
Child #2 Grade Level *
Child #3 Name *
Child #3 DOB *
Child #3 Gender *
Child #3 School Attending *
Child #3 Grade Level *
Child #4 Name *
Child #4 DOB *
Child #4 Gender *
Child #4 School Attending *
Child #4 Grade Level *
I authorize UniverCity 360 to access and use my child(ren) academic and social progress information related to the activities they participate in during the school year.  This information may be reported to all program funders for the purpose of demonstrating the effectiveness of UniverCity 360's initiatives. *
Do you give UniverCity permission to take photos, film videos and release the content on its website and social media platforms? *
Do you need any additional assistance? If so, please explain. *
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