Penns Manor Elementary After School Club Paperless Application - 2025-2026
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Child's Last Name *
Child's First Name *
My child would like to attend on the following days.  Please check all that apply. *
Required
Student's Date of Birth
 *
MM
/
DD
/
YYYY
Grade Level for the 25-26 School Year *
What is the name of child's homeroom teacher for the 25-26 school year? *
Race *
Gender *
Child's Physical Street Address
*Ex. 10775 Route 56 Hwy East
 *
PO Box:
If none, please skip this question
City/Municipality
 *
Zip Code
 *
Parent/Guardian 1: Full Name
 *
Parent/Guardian 1: Relationship *
Parent/Guardian 1: Phone #
Example 111-111-1111
 *
Parent/Guardian 1:  Email Address
 *
Parent/Guardian 1: Street Address
If different than above.  If not, please skip this question
Parent/Guardian 1: Date of Birth
month/day/year
 *
MM
/
DD
/
YYYY
Parent/Guardian 2: Full Name
If no 2nd Parent/Guardian, please skip this and related questions.
Parent/Guardian 2: Relationship
Parent/Guardian 2: Phone #
Example 111-111-1111
Parent/Guardian 2:  Email Address
Parent/Guardian 2: Street Address
If different from above.  If not, please skip this question.
Parent/Guardian 2: Date of Birth
month/day/year
MM
/
DD
/
YYYY
Household Members

Please place a checkmark next to all household members who live with the child in the primary residence.  (The total is used for grant reporting purposes and is not identified with your household specifically.)
 *
Required
If more than one sibling (brothers/sisters), please indicate how many total siblings.
Is the child's primary residence a single-parent household?
 *
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