West Jackson Elementary                                            After School Program Pre-registration form
Due to the limited number of students we can serve in the After School Program,  we will conduct a lottery drawing for participants in the program.  If you would like for your student to be included in the drawing for a spot in the after school program, please complete this form before midnight on 5/15/2023. Forms will be collected through midnight on  5/15/2023 and a drawing will be completed on  5/18/2023. Drawings will be done by family and families will be contacted on 5/18/2023 with information about selections.  Any student not initially selected will be placed on a wait list and may be selected as spots become available.  If you are completing this form after  5/15/2023 you will automatically be placed on the wait list for the After School Program.   By completing and electronically signing this form, and accepting a spot in the After School Program, you are agreeing to pay the yearly registration fee of $15.00 and $35.00 flat fee per child per week regardless if they attend each day. Each week will need to be paid in advance prior to the week attending.
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First Name *
Last Name *
2023-2024 Grade of student *
Student 2 First Name:
Student 2 Last Name:
2023-2024 Grade of 2nd student
Student 3 First Name:
Student 3 Last Name:
2023-2024  Grade of 3rd student
Student 4 First Name:
Student 4 Last Name:
2023-2024  Grade of 4th student
Parent name *
Parent Phone Number: *
Parent Email: *
I agree to pay the $15.00 yearly registration fee per child (if selected for a spot). *
Required
I agree to prepay the flat weekly rate of $35.00 per child, the week prior to services rendered.   *
Required
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