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STEAM for Success After School
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Email
*
Your email
Child's Name
*
Your answer
Child's Teacher
Your answer
Child's Address
*
Your answer
Child's birthday
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MM
/
DD
/
YYYY
Guardian's Full Name & Relationship to Student
*
Your answer
Guardian's Phone Number
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Your answer
Guardian's Work Number
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Your answer
Guardian 2 Full Name & Relationship to Student
Your answer
Guardian 2 Phone Number
Your answer
Guardian 2 Work Number
Your answer
Guardian Employers:
Your answer
Guardian Email Addresses
*
Your answer
The following individuals have permission to pick up my child. These are individuals who can be called if there is an emergency and I cannot be reached. I understand I must notify STEAM for Success in writing if there are any changes. Please List names, relationship to student, and contact phone numbers.
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Your answer
Does your child have any medical conditions I need to be aware of?
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Your answer
Does your child have any allergies? If yes, please list below.
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Your answer
List any medications your child is currently taking:
Your answer
I agree to pay STEAM for Success LLC tuition for after school on or before the scheduled due dates per the 2022-2023 schedule and understand payment can be made online at
www.steamforsuccess.com
or by check made payable to STEAM for Success LLC.
*
I agree
I disagree
I agree to provide the following changes in person or in writing as soon as they occur, cell & work numbers, address, contact information for individuals authorized to pick up my child and medical needs.
*
I agree
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