Lyndon Town School Afterschool Registration 2023-2024

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Student Last Name *

Student First Name *

Date of Birth *

YYYY

Gender *

What grade will your child be entering? *

Kindergarten

First Grade

Second Grade

Third Grade

Fourth Grade

Fifth Grade

Sixth Grade

Seventh Grade

Eighth Grade

Parent/Guardian Name #1 *

Parent/Guardian Address #1 *

Parent/Guardian Phone # *

Additional Parent/Guardian Name *

Additional Parent/Guardian Address *

Additional Parent/Guardian Phone Number *

Emergency Contact Name *

Relationship to the Student *

Emergency Contact Number *

Emergency Contact Name
*

Relationship to Student
*

Emergency Contact Phone Number
*

Please list any individuals that will be picking your child up from afterschool. *

Please provide the best email address(es) to use to contact you with information about Afterschool *

Does your child have any allergies or health conditions we should be aware of? *

What does your child need help doing? *

Does your child receive support services during the school day? *

IEP

504

Our family is open to a flexible starting date/okay with other families being prioritized first *

Yes, please add us to the waiting list

No, being added to the waiting list will cause a hardship for our family

Any additional comments? *

If you are able to make a financial contribution to help our program grow, please make a note below. We appreciate y our support - every dollar will make a big difference! I am able to make a contribution to help expand KEAP's offerings for kids. (You will receive a reminder of your noted amount during the session. Checks should be payable to Kingdom East School District) *

Not at this time.

$10.00

$25.00

$50.00

$100.00

Other Amount

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