InTouch After School Program Registration

After School Care
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list. The cost is $50 per week through January 1, 2020, then $60 per week.
After School Care Registration
Grade Attending
School Attending
Student Information
Student Name
First NameMiddle NameLast Name
Gender
Home Phone Number
Area CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Health Care Number
Doctor's Name
Doctor's Phone Number
Area CodePhone Number
Parent/Guardian Information (1)
Parent Guardian (1) Name
First NameMiddle NameLast Name
Home Phone Number
Area CodePhone Number
Cell Phone Number
Area CodePhone Number
Work Phone Number
Area CodePhone Number
Parent/Guardian (1) E-mail
Address same as child?
Address if different than the child. If your address is different than the child's please fill out the info below. Otherwise move onto the next section.
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Home Phone Number
Area CodePhone Number

Parent/Guardian Information (2)
Parent Guardian (2) Name
First NameMiddle NameLast Name
Home Phone Number
Area CodePhone Number
Cell Phone Number
Area CodePhone Number
Work Phone Number
Area CodePhone Number
Parent/Guardian (2) E-mail
example@example.com
Address same as child?
Address if different than the child. If your address is different than the child's please fill out the info below. Otherwise move onto the next section.
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code

Other Information
Is the child immunized?
Does the child have any allergies? If yes, list any food or drug allergies below.
Does the child have any medical conditions? If yes list any medical conditions below.
Does the child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed above?
Please list the people authorized to pick up your child.
Does your child have any siblings? If yes, list their name and age(s) below.
Emergency Contact - Other than Parent/Guardian
Emergency Contact Name
First NameMiddle NameLast Name
Emergency Contact Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Home Phone Number
Area CodePhone Number
Cell Phone Number
Area CodePhone Number
Work Phone Number
Area CodePhone Number
All registrations are received and reviewed on a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Parent/Guardian Signature
Clear
Should be Empty:

After School Care