After Care - Special Program Registration Form 2017 - 2018
2017-2018 School Year (Program is run under the auspices of the After Care Program.)
Email address *
Program Registering For: *
Name: *
Your answer
Class: *
Address:
Your answer
Home Phone: *
Your answer
Cell Phone: *
Your answer
Email Address *
Your answer
Additional Contact 1:
Your answer
Additional Contact 2:
Your answer
What would you like the instructor/ staff to do in the event of an emergency? *
Your answer
Does your child have an allergy? *
Required
If yes, please indicate allergies.
Your answer
Does your child's allergy require an Epi Pen to be administered? *
Required
Will you be supplying After Care/ Zumba/Edible Art with an EpiPen?(separate from the one provided for the normal school day) *
Required
Are there any specific medical conditions or issues of concern? *
Required
If yes, please explain briefly.
Your answer
The following people are given permission to pick up my child/children from the Zumba/Edible Art/Drama: *
Your answer
The following people are not permitted to pick up my child/children from Zumba/Edible Art/Drama: *
Your answer
Please complete the captcha before submitting the form.
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