Step Up After School Registration

Student Enrollment Date:

Name:*

First

Last

Date of Birth:*

day

month

year

Age:*

Gender:*

Male

Female

Address:*

Street AddressCityState / Province / RegionPostal / Zip Code

PARENT/GUARDIAN INFORMATION:

Parent Name:*

First

Last

Spouse Name:*

First

Last

Home Phone:*

Area Code

Phone Number

Cell Phone:*

Area Code

Phone Number

E-mail:*

Place of Employment

Work Phone:*

Area Code

Phone Number

Child lives with?*

EMERGENCY CONTACT (other than parent):

Contact Name:*

First

Last

Contact Address:*

Street AddressCityState / Province / RegionPostal / Zip Code

Contact Phone:*

Area Code

Phone Number

SCHOOL INFORMATION:

Please answer important health information give details where necessary.

Chronic Health Problems: (Asthma, Diabetes, other; if yes explain) *

Medications: (if yes, please list)*

Allergies: (if yes please list All Food/Medications)*

Personal Physician: (name and phone number)*

Physical Disability: (if yes, give details)*

Psychological Disability: (if yes give details)*

Please read the following statements before signing below:

I hereby certify that my application contains no false information and is complete, truthful, and accurate to the best of my ability.
I authorize medical treatment for my child in the case of emergency; I authorize ambulance or emergency services transportation to doctor or hospital.
I give permission for photographs of my child in class, during trips or events to be used for advertisement and marketing campaigns associated with the after school program.

Your Electronic Signature*

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