After-School Program Enrollment Form
Participant Information
Child's Full Name
Date of Birth
Current Grade
School Name
Parent/Guardian Information
Parent/Guardian Name
Relationship to Child
Phone Number
Email Address
Home Address
Emergency Contact
Emergency Contact Name
Emergency Contact Phone
Relationship to Child
Other Information
Medical Concerns/Allergies
Select Days Attending
How will your child get home?
Pick-Up
Walk
Other
Additional Notes