After School Program

Registration

Reserve a spot for your student. Required fields are marked with *. Your answers are saved on this device as you type — if you leave the page, you can pick up where you left off.

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Application received

Thank you — we have your registration and will be in touch soon to confirm your student's spot. Everyone's welcome at the table.

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Student information

Student full name *

Date of birth *

Grade / current school

Gender

Home address

City

ZIP code

Parent / Guardian 1

Full name *

Relationship to student

Primary phone *

Email address

Home address

Parent / Guardian 2 (optional)

Full name

Relationship to student

Primary phone

Email address

Home address

Emergency contact

Name (if different from above)

Phone

Program & transportation

Days attending (check all that apply)

Mon Tue Wed Thu Fri

Requested start date

Intended pick-up time

Does the student need transportation from school to the program?

Yes No

Academic support needed

Check the subject(s) where the student needs extra help.

Math Reading / ELA Writing Science Spanish Social Studies Other

If "other," please specify

Language

Is the student bilingual?

Yes No

Preferred language at home

Language most comfortable for schoolwork

Health & additional information

Allergies or medical conditions

Behavioral / learning / accommodation notes

Photo / media release for social media and promotional use?

Yes No

Authorized pick-up persons

In addition to the parents/guardians listed above. Bring a photo ID for each person when you visit the club — we'll verify it in person.

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone