Child & Family Information
PARENTS: Please complete one separate form for EACH CHILD in your household who will be participating in After School Care for the month of SEPTEMBER. ***Please note: the cost per child is $6/hour, rounded to the nearest :10 minutes***
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Email *
Child's Last Name: *
Child's First Name: *
Child's Grade: *
Child's Teacher (if known):
Name of parent/guardian completing form: *
Primary Contact Phone # *
Please list the names of anyone who may be expected to pick up your child: *
Does this child have other siblings who will be coming to our program? *
Is there anything else you would like us to know about your child (Allergies, special concerns, etc.)? *
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