Waitlist *2019-2020 After School Program
Students who participate in the program will receive instruction emphasizing social and emotional development, cross-curricular learning in math and reading, as well as problem solving and critical thinking skills.

The program begins Tuesday, November 12th and ends in May of 2020.

The program will be held on Tuesdays and Thursdays from 3:05-5:00 pm.

All children will be ready for dismissal promptly at 5:00 P.M. in the upper playground of the school/and or gym.

Any questions, please feel free to email Coordinator Zakiyyah A. Cobb zcroseberry@twpunionschools.org
Student Name: *
If you have more than one child, please complete a separate form for each child participating.
Your answer
Grade *
What grade is the student in
*
Will your child be joining us for this After School Program?
For students who walk home:
Emergency Contact Information
Parent (or Legal Guardian) Name: *
Parent 1 (ex. Mother)
Your answer
Parent (or Legal Guardian) Cell Phone Number: *
Parent 1 (ex. Mother)
Your answer
Parent (or Legal Guardian) Name:
Parent 2 (ex. Father)
Your answer
Parent (or Legal Guardian) Cell Phone Number:
Parent 2 (ex. Father)
Your answer
Email Address:
Your answer
Home Address: *
Your answer
Home Phone Number: *
Your answer
#1 Emergency Contact Name & Relationship: *
The name & relationship of your emergency contact can be listed here. (ex. Jane Doe-Aunt)
Your answer
#1 Emergency Contact Number: *
The name & relationship of your emergency contact can be listed here. (ex. Jill Doe-Cousin)
Your answer
#2 Emergency Contact Name & Relationship:
Your answer
#2 Emergency Contact Number:
Your answer
Additional People to whom my child(ren) may be released:
Please enter Name, Relationship and Phone Number of additional people to whom your child may be released. You may list up to 2 additional people. (ex. Jane Doe-Aunt-1234567890, Jill Doe-Cousin-1234567890)
Your answer
Parent Signature *
Please sign, initial and date form before submitting. (Ex. John Doe J.D. 6/21/19)
Your answer
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