After School Program Registration

Child 1 Full Name:

Teacher:

Child 2 Full Name:

Teacher:

Child 3 Full Name:

Teacher:

Grade:

Mother's Name:

Mother's Cell Phone:

Home Address:

Father's Name:

Father's Cell Phone:

Email:

Emergency Contact During ASP Hours:

Names and numbers of people who may pick up your child from ASP (other than parents):

Please list any health conditions/allergies your child may have. If Benadryl, epipen, inhaler or any other medications are used, we must have these each day with us in the ASP along with a copy of your child’s emergency care plan from the school office.