CCASP Registration Form

After School Program Registration Form

Please fill out one form per child. Read through carefully and fill out the required areas.
Please note that our current fee is $25 per month.

You can pay monthly or you can pay for a full year at $250.

You can also pay in three installments:
- $25 monthly
- $62.5 quaterly
- $250 yearly
For financial assistance, please email Youth@cmaalowell.org or call

978-454-6200 after submitting this form.
Child Information
Child's Full Name*

First NameLast Name
Birth Date*
MM/DD/YYYY
Gender*
Race
Ethnicity
Cambodian, Chinese, Vietnamese, etc.
Full Address*
ex: 465 School St, Lowell, MA 01851
Is your child a returning student of the after school program?*
Current School*
Current Grade*
Parent/Guardian Information
Parent/Guardian Full Name*
Relationship to Child*
Parent/Guardian E-mail*
example@example.com
Parent/Guardian Mobile Number*
Format: (000) 000-0000.
Emergency Contact Full Name*
This cannot be the same as Parent/Guardian portion.
Relationship to Child*
Emergency Contact E-mail*
example@example.com
Emergency Contact Mobile Number*
Format: (000) 000-0000.
Does your child have any medical condition, allergies, or medication we need to be aware of? If no, please type N/A.*
Household Information
How many people are in your household? (family and non-family members)*
How many people in your household are working adults?*
How many people in your household are under 18?*
What is your estimated household yearly income?*
Pick Up and Drop-Off Information
Will you (parent/guardian) or the emergency contact be the primary persons to drop-off and pick up your child?*
If you wish to add an additional drop-off/pick-up person that is not the parent/guardian, please provide their name, phone number, and relationship to you. If there are multiple drivers, please list them all below.
EX: John Smith, 000-000-0000, designated taxi driver
Please be advised that a fee will be applied for repeated early drop-offs and late pick-ups. Specifically, there will be a charge of $5 per day for any early drop-offs, and $5 per day for any late pick-ups.
Electronic Signature Acknowledgement and Consent Form

I/We agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and all statements above are correct and true to the best of my/our knowledge.
Student Full Name*
Date*

MonthDayYear
Date
Parent/Guardian Full Name*
Date*

MonthDayYear
Date
Should be Empty:

After School Program Registration Form

Child Information

Parent/Guardian Information

Household Information

Pick Up and Drop-Off Information

Electronic Signature Acknowledgement and Consent Form