Game Changers: After-School Registration Form
A form must be completed for every child participating in the after-school program.
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Birthdate: 
Sex: 
Age:
Last Name:
First Name:
Preferred Name:
Physical Address:
City: 
State:
Zip Code:
Home Phone:
Cell Phone: 
Other: 
Attending School Name:
Grade: 
Father's Information: (if applicable)
Last Name:
First Name:
Contact Phone Number:
Email Address: 
Mother's Information: (if applicable)
Last Name:
First Name:
Contact Phone Number:
Email Address: 
Emergency Contact (other than parent):
Name: 
Phone Number:
Note any Medical Issues or Allergies:
I give permission for my child to attend Game Changers After-school program.  I understand that my child will be transported to the program on a Game Changer van and that I will be responsible for picking my child up from the program everyday before 6pm or I will be charged a late fee.  I understand that my child may be suspended or expelled from the program at anytime due to misbehavior or discipline issues as determined by the Program Director.  I also give permission for my child to be photographed and video taped for use in projects, brochures, and media releases.
Parent Signature:
Date: 
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