Parent or Guardian, please write your first and last name in the space below. *
Your answer
Please list a phone number with area code. We will use this number to contact you about the program and in the event of an emergency.
Your answer
How many children do you want to participate in the Aftrer School Program? *
Choose
1
2
3
4
5
6
Please list your child(ren) and grade level below. For example, if you want 3 of your children to attend, your list might look like this: Anna, 3rd; Michael, 2nd; David 7th *
Your answer
Name and phone number of person who will be picking up child between 5:45-6:15 each day. *
Your answer
By completing this form, I understand I am requesting my child(ren) be selected for participation in the after school program as described above. I will do my best to have my child(ren) participate each day Monday-Friday. I also understand my child(ren) must be picked up between 5:45 and 6:15 Monday through Friday. *
The school may provide the emergency contact form completed at the beginning of the school year for each child who is selected to attend the after school program (all FERPA safeguards will be in place). *
A copy of your responses will be emailed to the address you provided.