Bushland After-School Care - BASC
Registration Form 2026-2027
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Email *
Please Check One of the Following:   *
Required
If Part-Time, please check box days your child will attend:   *
Required
Child's Full Name *
Male or Female *
Required
Date of Birth *
MM
/
DD
/
YYYY
Grade *
Teacher Name
Are there any siblings in "BASC"? If YES, please list name's *
Who has legal custody of the children/child and what is the relationship? 

**Please provide BASC with a copy of the custody agreement, as applicable. 
 *
Parent or Guardian:  
Mother's Full Name *
Cell Phone Number *
Mailing Address *
Physical Address *
City *
State *
Zip Code *
Work Place *
Work Number *
Address of Business *
E-Mail Address *
Father's Full Name *
Cell Phone Number *
If address same check below or answer following questions: *
Required
Address
City
State
Zip Code
Work Place *
Work Number *
Address of Business *
E-Mail Address *
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