After School Care Registration 2022-23

Family & Residential Information

Primary Parent/Contact First Name *

Primary Parent/Contact Last Name *

Primary Parent/Contact Cell Phone

Primary Parent/Contact Email *

Street Address *

Unit number or C/O

Country

State *

City *

Zip *

Save Profile

Password *

Confirm Password *

Student Information

Student First Name *

Student Last Name *

Grade in September 2022 *

Other Emergency Contact (Name, Phone)

Relationship to child

Family Physician (name, phone)

My child is allergic to

In the event of an allergic reaction, please provide the following (epi pen, etc.)

Other physical conditions

Add Another

ASC Registration

After School Care Registration

Pledge Amount

Payment Frequency

Installment Amount

Payment Start Date

I have read the text

In the event of an emergency, I consent to have my child given emergency care or medical treatment as needed until I can be reached. I will be responsible for medical costs incurred in the event of an accidental injury.

My signature accepts the text *

Payment Information

Choose Payment Method

Credit Card Bank Account

Name on Card *

Card Number *

Expiration *

CVV *