Student Application

_____ I will use the After School Program on a regular basis

_____ I will use the After School Program occasionally or for emergencies

Parent Name __________________________________________

Address __________________________________________________

Phone number: Home ___________________________

Work ___________________________

Cell ____________________________

Emergency Contact: ___________________________________________

_______________________________________________________________

Note other persons who may pick up your child/children, if not parent. Or note persons who may never pick up your child/children from the After School Program.

______________________________________________________________________

_____________________________________________________________________

Name and grade of child/children attending the After School Program

________________________________________________________

Probable days of week your child/children will attend: _____________

_______________________________________________________

Approximate time for pick-up ______________________

Parent’s Signature ______________________________________________