College View Academy After-School Program 2020-2021

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Application Form
Monday-Thursday 3-5:30pm; Friday 1-4pm. Early-release days 12-4pm.

Email *

Personal Information: Please list the name and grade of each child. *

Mother: *

Father: *

Address: *

Billing Email: *

Main Pick Up Name & Phone Number: *

Alternate Pick-up Name & Phone Number: *

Emergency Contact & Phone Number: *

Child's Doctor & Phone Number: *

Does your child have any food allergies or dietary restrictions? Choose One: No / Yes (please explain) *

My child(ren) has/have permission to be released to the individuals listed above in the alternate pick-up & emergency contact sections. As is standard in child care programs, if I am past the designated time to pick up my child(ren) I will be charged a late fee of $1 per minute, per child. To the best of my knowledge all of the information provided is accurate. I agree to the terms outlined above. (Please sign and date below.) *

YYYY

Parent/Guardian Signature: *

Send me a copy of my responses.

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