After-School Program Application

 
Child's Name *
Child's Name
Birth Date *
Birth Date
Parent / Guardian Name *
Parent / Guardian Name
Home Address *
Home Address
Primary Phone Number *
Primary Phone Number
Secondary Phone Number *
Secondary Phone Number
Emergency Contact *
Emergency Contact
Emergency Contact's Primary Phone *
Emergency Contact's Primary Phone
Emergency Contact's Secondary Phone *
Emergency Contact's Secondary Phone

 After we review your application, we will contact you with an authorization and liability waiver.