22-23 21st Century After Hours Enrollment Form
This form is the information needed to enroll your student into the 21st Century After Hours Program.  Please complete the requested information as thoroughly as possible to begin the admission process.  Your student will be able to start the program once a bus route has been assigned and your signatures have been collected.  
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Email *
21st Century After Hours Program
Section I - General Student/Family Information
This is basic information required by the State of Ohio and the Warren City School District.  Please fill out completely.  
Which School does your student attend? *
Student First Name *
Student Last Name *
Student Date of Birth *
MM
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DD
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YYYY
Grade Level *
Parent/Guardian First Name *
Parent/Guardian Last Name *
Street Address       (ex. 123 Main St. Apt. 4) *
City *
State *
Zip Code *
Parent/Guardian Phone Number *
Please provide an active email address.   *
Parent/Guardian Alternate Phone Number *
Alternate Family Information
List a second parent or guardian
Parent/Guardian First Name *
Parent/Guardian Last Name *
Parent Guardian Phone Number *
Electronic Signature Section I *
By selecting the "I Agree" button, you are signing this section electronically.  You agree that your electronic signature is the legal equivalent of your manual/handwritten signature on section I of this document and that the statements given are true to the best of your knowledge.
Required
Electronic Signature Date *
MM
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DD
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YYYY
Section II - Authorization for Emergencies
List 3 Emergency Contacts Authorized to Take the Student from the Program
Name  of Person 1 *
Phone Number of Person 1 *
Name of Person 2
Phone Number of Person 2
Name of Person 3
Phone Number of Person 3
Name of your Student's doctor *
Phone Number of your Student's doctor *
Name of your Student's dentist *
Phone Number of your Student's dentist *
The staff of the 21st Century After Hours may provide First Aid and Transportation to Emergency Care Facilities. *
Electronic Signature Section II *
By selecting the "I Agree" button, you are signing this section electronically.  You agree that your electronic signature is the legal equivalent of your manual/handwritten signature on section I of this document and that the statements given are true to the best of your knowledge.
Required
Electronic Signature Date *
MM
/
DD
/
YYYY
Section III - Student Health Information
Do NOT leave this section blank.  Type NA for the portions for any or all portions that do NOT apply to your student
List the Student's Medical Health needs *
Type NA if None Apply
List the Student's Allergies/Treatments *
Type NA if None Apply
List the Student's Dietary Needs/Restrictions *
Type NA if None Apply
List the Student's Medications that may need to be administered during program time.   *
Type NA if None Apply
Electronic Signature Section III *
By selecting the "I Agree" button, you are signing this section electronically.  You agree that your electronic signature is the legal equivalent of your manual/handwritten signature on section I of this document and that the statements given are true to the best of your knowledge.
Required
Electronic Signature Date *
MM
/
DD
/
YYYY
THERE IS NO SECTION IV
Clear selection
Section V - Transportation/Activity Authorization
Complete to allow Child to leave program for specific activities with specific people.  Type NA if this does NOT apply to your student
Destination/Activity *
Type NA if None Apply
Authorized Adult Name *
Type NA if None Apply
Departure Time?
Type NA if None Apply
Time
:
Return Time?
Time
:
Duration of Activity/Departures in weeks or months
Type NA if None Apply
Electronic Signature Section V *
By selecting the "I Agree" button, you are signing this section electronically.  You agree that your electronic signature is the legal equivalent of your manual/handwritten signature on section I of this document and that the statements given are true to the best of your knowledge.
Required
Electronic Signature Date *
MM
/
DD
/
YYYY
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