Ivy League Kids After School Program
Pre-Registration
Student(s) Legal Name: *
Your answer
Grade: *
Your answer
Grade: *
Your answer
Gender: *
Required
Ethnicity *
Your answer
Special Needs *
Parent/Guardian (1) *
Your answer
Parent/Guardian (2)
Your answer
Physical Address: *
Your answer
Mailing Address: *
Your answer
Cell Phone: *
Your answer
Email: *
Your answer
Do You Receive Illinois Action for Children: *
EMERGENCY CONTACT: If a child becomes ill or is injured while attending the after-school program and parent/guardian cannot be contacted, the following people have permission to be contacted and released to: Name: Relationship: Phone: *
Your answer
If my child needs to be taken to an emergency facility, he/she will be taken to the nearest one. I give my consent for staff to take appropriate action for the safety and welfare of my child. (sign e- signature below) *
Your answer
Photos are taken occasionally and may be posted on the website/Facebook page of Adults Active in Youth Development, Inc. Consent give to take photos of child: *
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