Afterschool Meal Program Registration

Student's Full Name

First NameLast Name

Student's Date of Birth

Date

Grade Level

Parent/Guardian Name

First NameLast Name

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Email Address

example@example.com

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Does the student have any dietary restrictions or allergies?

Please list any other important medical information or special needs.

Days the student will participate in the meal program

Preferred meal type

Who is authorized to pick up the student?