Crafton UP After School Program
Registration Form
Child's Full Name (Last, First)
Your answer
Address
Your answer
City, State, Zip
Your answer
Home Phone #
Your answer
Cell Phone #
Your answer
Age, M/F
Your answer
Date of Birth
Your answer
Grade in Fall of 2016
Your answer
School Attending
Your answer
Name of Teacher (Last, First)
Your answer
Email
Your answer
Parent or Guardian?
Your answer
Parent or Guardian's Full Name (Last, First)
Your answer
Best Phone # for emergencies
Your answer
Parent or Guardian's Full Name (Last, First)
Your answer
Best Phone # for emergencies
Your answer
Child is in custodial care of (Check One)
May your child be released to anyone other than the custodial parent/guardian?
If Yes, please list who:
Your answer
Emergency Contact if parents cannot be reached: Full Name (Last, First)
Your answer
Phone #
Your answer
Does your child have any allergies? (Foods, drugs, etc.)
If Yes, Please list:
Your answer
Does your child currently take any medication of which we should be aware?
If Yes, Please list:
Your answer
Are you currently a member of a church? If yes, please provide the name.
Your answer
How did you hear about our program?
Your answer
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