Child's First Name (required)
Child's Last Name (required)
Child's Gender (required) FemaleMale
Child's Date of birth (required)
Child's Age (required)
School Name and City (required)
Grade (required) ---KindergartenFirstSecondThirdFourthFifthSixthSeventhEighth
Teacher's Name
Please list any specific needs of your child.
Please list any known allergies of your child.
Please list all medications your child is taking.
Does your child have a public library card? (required) YesNo
Program enrollment Information
Select your child's enrollment (required) ---After School onlyBefore School onlyBefore and After SchoolSummer Enrichment
Will you need transportation during the school year? (required) YesNo
What date do you need to start? (required)
Part-time schedule only - list the days of the week you will need service
Tell us about your child
My child's strengths are:
My child needs practice with:
My child enjoys:
What are your expectations for your child while participating in our program:
Parent/Guardian Information
First Name (required)
Last Name (required)
Address (required)
City (required)
State (required)
Zip Code (required)
Preferred Phone Number (required)
Parent Email address (required)
Who does your child live with? (Please list names/relationships)
Emergency Contact
Name (required)
Phone Number (required)
Relationship to child (required)
Who is authorized to pick up your child?
How did you hear about us? (required)
