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Arts and Enrichment After School Care Application 2022-2023
This form is to be used to indicate interest in the after school care program at Lauri Ann West Community Center for the 2022-2023 School Year.
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* Indicates required question
Email
*
Your email
First and Last Name of Student 1
*
Your answer
Date of Birth of Student 1
*
MM
/
DD
/
YYYY
Grade Level of Student 1 for 2022-2023 School Year
*
Choose
K
1
2
3
4
5
6
School of Student 1
*
Choose
O'Hara
Fairview
Hartwood
Kerr
Dorreysville Middle
First and Last Name of Student 2
Your answer
Date of Birth of Student 2
MM
/
DD
/
YYYY
Grade Level of Student 2 for 2022-2023 School Year
Choose
K
1
2
3
4
5
6
School of Student 2
Choose
O'Hara
Fairview
Hartwood
Kerr
Dorreysville Middle
Days Interested in Attending (You must attend two days a week in order to participate in our program.)
*
Monday (waitlist only)
Tuesday (waitlist only)
Wednesday (waitlist only)
Thursday (waitlist only)
Friday (waitlist only)
Required
Primary Parent/Guardian Name (First and Last)
*
Your answer
Primary Parent/Guardian Contact Phone
*
Your answer
Primary Parent/Guardian Contact Email
*
Your answer
Are you interested in our scholarship opportunity?
*
Yes
No
Send me a copy of my responses.
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