21st Century After School Program Application
(2018-2019 School Year) Please ensure all information entered is accurate to avoid enrollment delay or decline.
Email address *
Scholar #1 First Name *
Your answer
Scholar #1 Last Name *
Your answer
Scholar #1 Date of Birth *
MM
/
DD
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YYYY
Scholar #1 Grade *
Scholar #1 Medical Needs/Restrictions: List ALL allergies, prescribed medications, behavior disorders, learning disabilities, or medical diagnosis. Please be detailed so that we can best assist your scholar.
Your answer
Scholar #2 First Name (Please fill out one application for all siblings or list n/a) *
Your answer
Scholar #2 Last Name *
Your answer
Scholar #2 Date of Birth *
MM
/
DD
/
YYYY
Scholar #2 Grade *
Scholar #2 Medical Needs/Restrictions: List ALL allergies, prescribed medications, behavior disorders, learning disabilities, or medical diagnosis. Please be detailed so that we can best assist your scholar.
Your answer
Scholar #3 First Name *
Your answer
Scholar #3 Last Name *
Your answer
Scholar #3 Date of Birth *
MM
/
DD
/
YYYY
Scholar #3 Grade *
Scholar #3 Medical Needs/Restrictions: List ALL allergies, prescribed medications, behavior disorders, learning disabilities, or medical diagnosis. Please be detailed so that we can best assist your scholar.
Your answer
Mailing Address *
Your answer
Lunch Status? *
Ethnicity *
Required
Students lives with: *
Check box if legal restrictions or custody orders apply (please note this information will be used for the dismissal process) *
Required
Parent/Guardian First & Last Name *
Your answer
Parent/Guardian Email Address *
Your answer
Contact Number *
Your answer
#1 Emergency Contact First & Last Name (this name will be added to your scholar's authorized pick up list) *
Your answer
Relation to child *
Your answer
Phone Number *
Your answer
#2 Emergency Contact First & Last Name (this name will be added to your scholar's authorized pick up list) *
Your answer
Relation to child *
Your answer
Phone Number *
Your answer
#3 Emergency Contact First & Last Name (this name will be added to your scholar's authorized pick up list)
Your answer
Relation to Child
Your answer
Primary Phone Number
Your answer
#4 Emergency Contact First & Last Name (this name will be added to your scholar's authorized pick up list)
Your answer
Relation to Child
Your answer
Primary Phone Number
Your answer
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