AFTER SCHOOL PROGRAM REGISTRATION FORM Complete this form, print it out ('File', and 'Print' on your browser) and submit this as part of your registration packet to the school office.
Select Program:		Choose One After School Program Before School Program Both		Date:
Child's Name:				Grade:
Child's Name:				Grade:
Child's Name:				Grade:
Parent's Name:				Phone:
Address:
Business Address: Father:				Business Phone:
Mother:				Business Phone:
Who will pick up your child?				Approx. Time:
Relationship:

List of pick up alternatives:
Name:				Relationship:				Phone:
Name:				Relationship:				Phone:
Name:				Relationship:				Phone:
Emergency Contact:
Name:				Phone:
Physician in Case of Emergency
Name:				Phone:

Please check days child/children will be attending the After School Program. Monday Tuesday Wednesday Thursday Friday
Please indicate choice of payment and plan: Choose Plan 3 Day 5 Day As Needed Choose Payment FACTS Program Check / Cash
Signature of Parent / Guardian: ________________________________________________________________________________