After School Program Registration Form
Student’s Name: _____________________________________ Phone #:
________________
Grade & Section: ___________ Bus #: _______________
Does your child wish to be considered for the program both
Tuesday and Thursday? Yes / No
Please enroll my child in the following class (es):
1.) _________________ ________________________________________________
Day Offered
Class Name
2.) _________________ ________________________________________________
Day Offered
Class Name
3.) _________________ ________________________________________________
Day Offered
Class Name
4.) _________________ ________________________________________________
Day Offered
Class Name
Emergency Contact Information - Please fill out completely
Does your child participate in the YMCA program in our building after school?
____________
Parent’s Last Name: _________________________ First Name:
________________________
Home Address: _________________________________________________________________
Home Phone: ______________________________ Cell Phone:
__________________________
Mother’s Work # ________________________ Father’s Work #
__________________________
E-Mail Address: _______________________________________________________________
Emergency Contact Names and Phone Numbers:
1.
___________________________________________________________________________
Name Relationship to Child Phone
2.
___________________________________________________________________________
Name Relationship to Child Phone
Please list allergies or medical information: __________________________________________
Volunteer Opportunities
I am willing to be an After School Program Monitor on the following days:
Tuesdays: 02/12 _____ 02/19 ______02/26 ______03/04_____ 03/11 _____ 03/18
______
Thursdays: 02/07 _____ 02/14 ______02/21 _____ 02/28 _____ 03/06_____ 03/13
______
PICK-UP FOR THE AFTER SCHOOL PROGRAM
ON TUESDAY AND THURSDAY IS 4:45 P.M.