After School Program Registration Form

PARENT/ GUARDIAN INFORMATION

Address

SECOND PARENT/ GUARDIAN INFORMATION

Address

EMERGENCY CONTACT

CHILDREN'S INFORMATION

What school will your children be registering for? *

Will your children or child require full time or part time care? *

If part time, please indicate the days of the week required

First Childs First Name *

First Childs Last Name *

What grade will your child be attending.? *

Does this child have any allergies, chronic illness, or medical conditions? If yes, please describe

Does this child have any special needs or require supports/assistance that we should be aware of?

Do you give permission for Play 4 Kids to post and use media that may have your child in it. *

Second Childs First Name

Second Childs Last Name

What grade will your child be attending.?

Does this child have any allergies, chronic illness, or medical conditions? If yes, please describe

Does this child have any special needs or require supports/assistance that we should be aware of?

Do you give permission for Play 4 Kids to post and use media that may have your child in it?

Third Childs First Name

Third Childs Last Name

What grade will your child be attending.?

Does this child have any allergies, chronic illness, or medical conditions? If yes, please describe

Does this child have any special needs or require supports/assistance that we should be aware of?

Do you give permission for Play 4 Kids to post and use media that may have your child in it?

PAYMENT INFORMATION

What is your preferred method of payment? *

An application fee of $25 will be applied upon acceptance *

Billing will occur on the 20th of each month for 10 consecutive months *

Two weeks notice is required to withdraw or change registration. Time will be billed accordingly. *

I understand students may not attend until confirmation of acceptance has been received? *

I understand that Parents/Guardians must notify the office of changes to emergency contact info *

I understand that payment info is not to be sent via email *

I understand that applications must be submitted each year for returning students. *

I have read and understand all of the program literature in the Parent Handbooks *