ABS Before & After School Care Registration and Payment Agreement
Please read the ABS Before & After School Care Handbook BEFORE filling out this form. https://docs.google.com/document/d/1EdmcvzUbka5CDgklaf34pInDuu6hQY6i3keX29qMd-8/edit?usp=sharing


PLEASE FILL OUT ONE FORM PER CHILD

Child's FIRST Name *
Your answer
Child's LAST Name *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Grade level for 2019-2020 *
Parent 1 - Name *
Your answer
Parent 1 - Contact Phone Numbers *
Your answer
Parent 1 - Email Address *
Your answer
Parent 2 - Name ( or n/a if doesn't apply) *
Your answer
Parent 2 - Contact Phone Numbers (or n/a if doesn't apply) *
Your answer
Parent 2 - Email address (or n/a if doesn't apply) *
Your answer
Street Address (where student resides) *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Parent 1 place of work *
Your answer
Parent 1 work phone *
Your answer
Parent 2 place of work (or n/a if doesn't apply) *
Your answer
Parent 2 work phone (or n/a if doesn't apply) *
Your answer
Emergency contact name and phone number (other than parent) - Who should we call if you can't be reached? *
Your answer
Authorized Pick-Up List - List full name and relationship to your child of those who have permission to pickup your child from the Arts Based Before & After School Care Program. *
Your answer
Please list any student limitations or health concerns we need to know about: *
Your answer
Please list any allergies to food or medication your child may have. (explain reaction to exposure) *
Your answer
Please list any medication your child will need to take during Before & After School Care. *
Your answer
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