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After School Program Registration Form 2022-2023
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* Indicates required question
Email
*
Your email
Family last name
Your answer
Child 1, grade level
Your answer
Child 2, grade level
Your answer
Child 3, grade level
Your answer
Are any of the children being registered have any medical conditions /allergies? If so, please note below
Your answer
Contact Information:
Parent(s) name(s)
Your answer
Home address
Your answer
Home phone
Your answer
Mother Cell Phone
Your answer
Father Cell Phone
Your answer
Authorized Pick-ups- other than parent*
Please list below:
Name
Your answer
relationship
Your answer
contact number
Your answer
Name
Your answer
relationship
Your answer
contact number
Your answer
Sessions attending
Days attending for Child 1
Monday
Tuesday
Wednesday
Thursday
Days attending for Child 2
Monday
Tuesday
Wednesday
Thursday
Days attending for Child 3
Monday
Tuesday
Wednesday
Thursday
Fees
Payment Method- beginning of each month*
check
Clear selection
Family Monthly Rate- One Child
One day a week per month ( $80.00)
Two days a week per month ($150.00)
Three days a week per month ($220.00)
Four days a week per month ($290.00)
Family Monthly rate- Two Children
One day a week per month ( $150.00)
Two days a week per month ($290.00)
Three days a week per month ($430.00)
Four days a week per month ($570.00)
Family Monthly rate- Three Children
One day a week per month ( $220.00)
Two days a week per month ($430.00)
Three days a week per month ($640.00)
Four days a week per month ($850.00)
Would you like to purchase a 10-pack drop-in sessions for use any time during the year with 24 hour notification via email
asp@ollmalverne.org
10 sessions- ($200.00)
20 sessions ($400.00)
Any additional questions or comments about ASP? Please submit below.
Your answer
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