STEM4kids - After School Program 2019-2020
Registration Form
Email address *
Parent/Guardian Information
Mother/Guardian First and Last Name *
Mother/Guardian Address *
Mother/Guardian Email Address *
Mother/Guardian Home Phone
Mother/Guardian Cell Phone *
Mother/Guardian Work Phone
Father/Guardian First and Last Name *
Father/Guardian Address *
Father/Guardian Email Address *
Father/Guardian Home Phone
Father/Guardian Cell Phone *
Father/Guardian Work Phone
Emergency Contacts:
First Contact Name *
First Contact Phone Number *
First Contact Relationship *
Second Contact Name
Second Contact Phone Number
Second Contact Relationship
List all individuals authorized to pick up your child (other than child’s parents). Unlisted persons will not be permitted to pick up our child. Identification may be requested from listed individuals.
First Contact Name *
First Contact Phone Number *
First Contact Relationship *
Second Contact Name
Second Contact Phone Number
Second Contact Relationship
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