After-School Program Registration 2024-2025
This release and registration form must be filled out completely with current information, agreed upon, signed and turned in before the participant will be allowed to attend the program. All outstanding accounts must be paid in full to attend the program. This form is for the health and safety of the participant.

There will be no ASP on Half-days, holidays, vacation weeks, or in-service days. If school cancels all after school activities that will include rec.

We will take the first 30 students that are registered. You will be charged by the month, it will be $200 per month per child for full time (if there is a vacation week during that month, it will be $150), or $110 for part-time (if there is a vacation week during that month, it will be $85).  If your child doesn't come to rec one day you will not get a refund for those days; if we have to cancel due to staffing you will get a $10 credit to you account per day. Payment will be due by or on the 1st of EVERY month.

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Email *
Participant's Name *
Grade Entering *
Teacher *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Gender *
Address *
Does the participant have a disability that requires assistance? *
Identify any behavior concerns and how to handle them *
If none, please write N/A
Limitations/Restrictions/Diet *
If none, please write N/A
Is participant taking medication? *
Name of medication *
If none, please write N/A
Will medication be taken during program hours? *
Any medical conditions we should be aware of? *
Allergy? Asthma? Seizures? Diabetes? Other?
Allergies?
Any other information that would be helpful to staff? *
Part Time or Full Time *
Participant may be dismissed for the following activities:
Parent/Guardian Name *
Relationship *
Address (if different)
Mobile *
Home Phone *
Work Phone *
E-Mail *
Parent/Guardian
Relationship
Address (if different)
Mobile
Home Phone
Work Phone
E-Mail
Person to Notify in Emergency *
Name, Number, Relationship
Person to Notify in Emergency
Name, Number, Relationship
Person to Notify in Emergency
Name, Number, Relationship
Physician's Name *
Physician's Phone Number *
Medical Coverage
Group ID #
Preferred Hospital *
The following people are authorized to pick up participant at the site: *
Name, Relationship, Phone
Releases and Clauses
Do you agree with the above clauses and releases? If not, the participant will not be able to be enrolled into Rec. *
If you agree, below please give: signature, relationship to participant, and date
Submit
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