2020-2021 After School Kids club
Monday-Friday from 3pm-6pm
Student Name *
Student Grade *
Days Per Week - mark all that apply
Will Attend
until 4pm
until 5pm
until 6pm
Only on occasion
Monday
Tuesday
Wednesday
Thursday
Friday
Mother's Name
Mother's Cell
Father's Name
Father's Cell
Family Physician's Name and Phone
Family Dentist Name and Phone
Please list any other phone numbers where you can be reached in case of an emergency
If there is anything pertinent to your child's care that we should know?
Students will only be released to individuals listed on the student release.
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