After-school Program Registration Form
We are currently enrolling students in our free after-school program that will launch this spring, starting February 6. We can host 15 students ages 8 to 18 each day, Monday through Friday from 3pm to 6pm. We ask that parents sign their students up for at least tho days per week, and will prioritize students by need and location. Our goal is to serve kids and teens who are in need of financial assistance and live near our center located at 2301 Telegraph in Oakland.

After you fill out this registration form, we will get in touch to meet you and your child or children.

What days of the week will your student be attending our after-school program (two days minimum) *
Required
Full name of student (first and last) *
Your answer
Date of Birth *
Your answer
Grade *
Race/Ethnicity *
Home Address *
Your answer
Mailing address (if different from home address) *
Your answer
Parent/Legal Guardian (full name)
Your answer
Student's Gender *
Student's email (optional)
Your answer
Student's phone number (optional)
Your answer
Parent's email *
Your answer
Parent's phone number *
Your answer
In the case of emergency contact *
Your answer
In the case of emergency contact's relationship to student *
Your answer
Emergency contact phone number *
Your answer
Emergency contact number two *
Your answer
Emergency contact number two's relationship to the student *
Your answer
Emergency contact number two's phone number *
Your answer
Does your child have health coverage? *
Name of medical insurance
Your answer
Policy #
Your answer
Medical history/allergies that may be of importance
Your answer
Medication that student is taking
Your answer
Name of child's doctor
Your answer
Dr./Medical group's phone number
Your answer
I authorize Chapter 510's staff to furnish and/or obtain emergency medical treatment which may be necessary for my child during their time at our writing center *
Required
Thank you for registering your child four our after-school program. We will be in touch soon to arrange a time to meet and talk more about our program.
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