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Lowpoint-Washburn
C.U.S.D #21
21st
Century Community Learning Center Grant
After-School
Program
REGISTRATION
FORM
1. CHILD’S
INFORMATION:
Name of
student:__________________________________________________________
Age:___________
Sex: M/F
Birthday:_______________
Address:________________________________________________________________
Zip
Code:____________________ Phone
Number:_____________________________
Grade:_______________________
Teacher:___________________________________
2. PARENT(s)/GUARDIAN(s)
IDENTIFICATION:
Name of
parent/guardian:___________________________________________________
Relationship to child:
________________________ Home Phone:__________________
Address:
________________________________________________________________
Employer:__________________________________Department:
___________________
Work
Hours:________________________________ Work Phone:
_________________
Name of
parent/guardian:___________________________________________________
Relationship to child:
________________________ Home Phone: __________________
Address:
________________________________________________________________
Employer:
__________________________________ Department:__________________
Work Hours:
________________________________ Work Phone: _________________
(Please
see back)
3.
EMERGENCY CONTACTS:
Emergency
Contact:_______________________________________________________
Home
Phone:__________________ Work
Phone:_______________________________
Emergency Contact:
_______________________________________________________
Home Phone:
__________________ Work Phone: ______________________________
Emergency Contact:
_______________________________________________________
Home Phone:
__________________ Work Phone: ______________________________
4. SCHEDULE
INFORMATION:
My child will attend
the After-School Program: Full Time
(4-5 days/week)________
Part Time (2-3 days/week)________
One day a week
________
My child will attend
the After-School Program on the following days (Please circle):
M
T W
TH F
5. MEDICAL
INFORMATION:
My child has the
following allergies or health restrictions:_________________________
________________________________________________________________________
PLEASE NOTE ANY
INFORMATION YOU WOULD LIKE US TO KNOW ABOUT YOUR
CHILD:___________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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