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ASEP Enrollment Form 2023-2024
Please complete this document to enroll in our Afterschool Program
* Indicates required question
Email
*
Record my email address with my response
Parent/Guardian #1 Name
*
First and last name
Your answer
Parent/Guardian #2 Name
First and last name
Your answer
Email #1
*
Your answer
Email #2
Your answer
Phone number #1
*
Your answer
Phone number #2
Your answer
Child #1: First & Last Name
*
Your answer
Child #1 Grade Level
*
Choose
Primary (PK 4 - Kindergarten)
Lower Elementary (1st - 3rd Grade)
Upper Elementary (4th - 5th Grade)
Adolescents (6th - 8th Grade)
Child #1: Allergies--please list below
*
Your answer
Child #1: Any additional information we need to know about your child/children (custody issues, behavioral needs, medical needs, etc.)
Your answer
Child #2: First & Last Name
Your answer
Child #2 Grade Level
Choose
Primary (PK 4 - Kindergarten)
Lower Elementary (1st - 3rd Grade)
Upper Elementary (4th - 5th Grade)
Adolescents (6th - 8th Grade)
Child #2: Allergies--please list below
Your answer
Child #2: Any additional information we need to know about your child/children (custody issues, behavioral needs, medical needs, etc.)
Your answer
Child #3: First & Last Name
Your answer
Child #3 Grade Level
Choose
Primary (PK 4 - Kindergarten)
Lower Elementary (1st - 3rd Grade)
Upper Elementary (4th - 5th Grade)
Adolescents (6th - 8th Grade)
Child #3: Allergies--please list below
Your answer
Child #3: Any additional information we need to know about your child/children (custody issues, behavioral needs, medical needs, etc.)
Your answer
Alternate emergency contact if we are unable to reach you. Include name and phone number with area code.
*
Your answer
Please enter the name of each person who is authorized to pick up your child or children.
*
Your answer
Check one for program services payments
*
Cash/Check/Money Order - Payable to Goodwater Montessori School
ACH (requires the 5 questions below)
Required
If paying by ACH, please complete the Authoriation Agreement for preauthorized payments below. All fields are required.
I (we) hereby authorize Goodwater Montessori School, hearinafter called Company, to initiate debit entries to my (our) Checking account indicated below and the depository named below, hereinafter called Depository, to debit the same to such account.
ACH Depository Bank Name
Your answer
ACH - Name on Bank Account
Your answer
ACH Routing Number
Your answer
ACH Bank Account Number
Your answer
Submit
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