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JCS 2022/2023 AFTER SCHOOL REGISTRATION
(A separate form must be filled out for each student)
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* Indicates required question
Child's Last Name
*
Your answer
Child's First Name
*
Your answer
Child's Middle Initial/Name
Your answer
Child Address (Street, City, State, Zip)
*
Your answer
Child Lives With:
*
Your answer
Birthday (Month/Day/Year)
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
School Attended
*
Jessamine Early Learning Village
Brookside Elementary
Nicholasville Elementary
Red Oak Elementary
Rosenwald-Dunbar Elementary
Warner Elementary
Wilmore Elementary
All Day Only
Grade for 2021-22
*
K
1
2
3
4
5
Photo Release
*
I give JCS After School Program permission to use photographs of my child online. I understand that my child's name will not appear with their image
YES
NO
In order for us to partner with you in the best way, please let us know if your child has any special needs we may need to be aware of:
*
Behavioral needs
Emotional needs
Social needs
Other
None
Required
Comments on special needs:
Your answer
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