SPACE Registration 2020-21
Please complete all required fields below. Your application will be complete when this form is submitted and the SPACE has received your application fee of $50/new student or $40/returning student. Registrations are processed on a first-come, first-served basis.

Tuition rates per week for 2020-21:
1 day: $25, 2 day: $50, 3-day: $75, 4 or 5-day: $100
10% discount applies to second child in a family
Child's First Name *
Your answer
Child's Middle Name
Your answer
Child's Last Name *
Your answer
Child's Nickname
Your answer
Sex *
Date of Birth *
MM
/
DD
/
YYYY
Grade for 2020-21 school year *
Your answer
School attending in fall 2020 *
Home Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Home Phone
Your answer
Important Information (allergies, medical info, academic challenges, diagnoses, etc)
Your answer
Mother/Guardian's First Name *
Your answer
Mother/Guardian's Last Name *
Your answer
Mother/Guardian's Employer
Your answer
Mother/Guardian's Cell Phone *
Your answer
Mother/Guardian's Work Phone
Your answer
All of Mother/Guardian's email addresses to which you want communication to be sent *
Your answer
Mother/Guardian's Home Address (if different than student)
Your answer
Father/Guardian's First Name *
Your answer
Father/Guardian's Last Name *
Your answer
Father/Guardian's Employer
Your answer
Father/Guardian's Cell Phone *
Your answer
Father/Guardian's Work Phone
Your answer
All of Father/Guardian's email addresses to which you want communication to be sent *
Your answer
Father/Guardian's Home Address (if different than student)
Your answer
Primary language spoken at home *
Your answer
Parents are *
Child lives with *
Required
List names and ages of other children in the same household
Your answer
Emergency Contact 1 Name (2 are required by VA state law) *
Your answer
Relationship to Student *
Your answer
Primary Phone Number *
Your answer
Emergency Contact 2 Name (2 are required by VA state law) *
Your answer
Relationship to Student *
Your answer
Primary Phone Number *
Your answer
List persons authorized to pick up child
Your answer
My child is a *
My child will attend *
If part time, choose which days
By signing below, the parent/guardian states that the information on this form is true and current to the best of their knowledge. I hereby agree to enroll my child in the afterschool program at the SPACE, and I agree to abide by the policies set forth in the handbook. *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Gayton Baptist Church. Report Abuse