Leesville Before/After School Program Registration
2017-2018 School Year
Email address
Name Child is to be called:
Your answer
Student's Full Name
Your answer
Child's NC Wise #
Your child probably knows this #. It is their lunch # and computer login #). If not, call the front office to find out. This is required to submit form. DO NOT enter a random made-up number!!!!
Your answer
Grade Level for the 2017-2018 School Year
Required
Please indicate the program(s) for which you are enrolling:
Required
Please specify the days you wish to enroll your child in Early Arrival
Please specify the days you wish to enroll your child in the After School Program
Address
Include city and zip code
Your answer
Child's First Day of Attendance at Program
Please make sure this is accurate! We rely on this to make sure your children get home safely!
Required
Primary Phone # (please attach a name to the number)
We'll call this first if we need you!
Your answer
Secondary Phone # (Please attach a name to the number)
We'll try this if we can't reach you on the first number
Your answer
Other Phone # (Please attach a name to the number)
We'll use this as a last resort!
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
Child's Age (as of 8/28/17)
Your answer
2017-2018 Homeroom Teacher
If you don't know yet, please tell us when you find out!
Your answer
Parent/Guardian's Name (s)
Your answer
Primary Email Address
Receipts will be sent to this address
Your answer
Additional email address
In case a second parent wants to stay "in the loop" with our communications!
Your answer
Father/Guardian's Place of Employment
Your answer
Mother/Guardian's Place of Employment
Your answer
Phone # to Father's Employment
Your answer
Phone # to Mother's Employment
Your answer
Emergency Contact(s)
Name, Phone #, Relationship to Student
Your answer
Name of Individuals to Whom the Program Staff May Release the Child as Authorized by the Person who Signs the Application
(We check ID!!) If this does not apply, just put N/A
Your answer
Student's Physician & Phone #
Your answer
Student's Dentist & Phone #
Your answer
Hospital Preference
Required
Does your child have any known food allergies?
We serve snack at after school
Required
If yes, please describe the nature of your child's food allergy
Your answer
Does your child have any chronic illnesses or conditions that we need to be aware of?
Required
If yes, please describe the nature of your child's illness or condition (ie. asthma, epilepsy, nosebleeds, etc)
Your answer
Does your child have an epi pen, inhaler, or any other medication that is kept in the main office at the school that we can access in the event of an emergency?
If yes, please indicate which is available
Required
Please give any other information that you would like the staff to know about your student (custody arrangements, special needs or interests, fears, behaviors, etc)
Your answer
After School Students Only: In the event of an early dismissal (due to inclement weather) and the After School Program is closed, how will your child get home?
By registering your child, you are agreeing you have read and accept the forms listed below, which you can find on our website (http://lesbeforeandaftercare.weebly.com)
please check each box below, after you have read each form on the Before/After Care website.
Required
Electronic signature
by electronically signing this registration form I am agreeing that I have read, accepted, and checked the: payment schedules, policies & procedures, and discipline policy listed above. I am also agreeing that all the information I have provided is correct and can be shared with the before/after care coordinator and staff.
Your answer
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
Submit
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