Before/ After Care Registration
Morning care will be from 7:00 am-8:30 am (Children will then be dismissed to the school). After-care will be from 4:00 pm-6:00 pm. Please fill out the form below in its entirety. A $25 registration fee and 1st-month tuition is due at the time of registration. You will receive a PayPal invoice via email before the close of the day. Forms of payments are PayPal, Money orders, or Check.) Thank you so much for choosing Something to Build Upon.
Email address *
Child's First Name *
Your answer
Child's Last Name *
Your answer
Age *
Your answer
Child's Address *
Your answer
Child's School *
Your answer
Child's Teacher *
Your answer
Gade *
Classroom Number
Your answer
Dietary Restrictions *
Food and Medical Allergies *please list all foods or medications your child cannot have *
Your answer
Physician's Name * *
Your answer
Physician's Phone Number * *
Your answer
List any health conditions *
Your answer
List any medications your child uses *
Your answer
Mother's First Name *
Your answer
Mother's Last Name *
Your answer
Mother's Email *
Your answer
Mother's Address *
Your answer
Mother's Phone Number *
Your answer
Father's First Name *
Your answer
Father Last Name *
Your answer
Father's Email Address
Your answer
Father's Address
Your answer
Father's Phone Number *
Your answer
Which parents does your child live with? *
List all persons that may pick your child up. *
Your answer
List any persons not allowed to be in contact with your child. *
Your answer
Emergency Contact Name and Phone Number *
Your answer
Who should receive the monthly invoices? * *
Will you be using Illinois Action for Children? *
Which service are you registering for? *
Payment *I understand that my deposit is non-refundable. You will receive a PayPal invoice within 2 business days. *
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service