Middle School After School Registration

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Thank you so much for your interest in our program!
To be registered for this program there are 3 easy steps to complete!

1. This on-line registration form.
2. You also will need to pay the first month fee or register for a scholarship to secure your spot.
3. Select your classes!

Email *

Last Name/ Apellido *

First Name/ Primer Nombre *

STUDENT INFORMATION/ INFORMACIÓN ESTUDIANTIL

Student's Campus *

My Student will require a bus ride home

Students Birth Date/ Fecha De Nacimiento (Month Mes / Day Día / Year Año) *

Sex/ Sexo *

Female

Male

OTHER

Ethnicity/ Raza *

WHITE, NOT HISPANIC/ BLANCO, NO HISPANO

HISPANIC/ HISPANO

AFRICAN AMERICAN

ASIAN

OTHER

MEDICAL INFOMATION/ INFOMACIÓN MÉDICA

If your child has a medical condition that requires special needs you must schedule a conference with the ASAP Coordinator.

Does the student require any medication? (oral medication, injections, eye or ear drops, etc.) If you answer YES, you will need to complete a Medication Authorization form available at your ASAP center.¿Requiere el estudiante algún medicamento? (medicamento oral, inyecciones, gotas para los ojos o los oídos, etc.) *

YES/ SÍ

Does the student need help with a medical procedure? (blood sugar, NG feeding, sterile catheterization) ¿Necesita el estudiante ayuda con un procedimiento médico? (análisis de azúcar en la sangre, alimentación por sonda nasogástrica, cateter-ización estéril) *

YES/ SÍ

Does the student have any other condition which causes the daily possibility of a life-threatening emergency? (inc. allergies or asthma) ¿Tiene el estudiante cualquier otro estado que causa la posibilidad diaria de una emergencia potencialmente mortal? (incluyendo las alergias o el asma) *

YES/ SÍ

Please list specific medical conditions, medications, and/or allergies if applicable.

Physical Address for Bus *

Mailing Address / Dir. Del Correo

Student Resides With: *

Mom

Dad

Both

Other:

Phone Number/ Numero Del Teléfono *

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