MathSeed After School
Child's First Name *
Your answer
Child's Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Home Address
Your answer
School *
Grade Level *
Day needed for after school service *
Monday
Tuesday
Wednesday
Thursday
Friday
Select all that apply
Start Date *
MM
/
DD
/
YYYY
Mother's Cell Phone *
Your answer
Mother's Work Phone
Your answer
Mother's Email *
Your answer
Father's Cell Phone *
Your answer
Father's Work Phone
Your answer
Father's Email *
Your answer
Emergency Contact Phone Number
Your answer
Authorized Pick-up Person Name
Please list the authorized adults who may pick up your child from the center. Your child must be able to recognize this adult and this adult must provide a valid government issued ID(driver’s license, passport) to pick up your child. Work badges or name tags will NOT be accepted as a valid form of ID
Your answer
Authorized Pick-up Person Phone
Your answer
Medication & Allergies *
Your answer
Primary Physician Name
Your answer
Primary Physician Phone
Your answer
Is your child a MathSeed student? *
Referred By
Print student first & last name
Your answer
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