After School Program Application (English)
Please complete this form to enroll your student in the afterschool program. Full packets with medical release will be sent home at the beginning of the school year. If enrollment is greater than space allows, program spaces will be filled by lottery drawing.

There is no school transportation available and all students will need to be picked up or given written permission to walk home.
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Student's Full Name *
Student's grade for 2020-2021  School year *
Student's cell phone number (if they have one)
Siblings
Mailing address *
Permanent Address *
Mother's Name *
Mother's  Phone number *
Mother's  employer and phone number *
Father's name *
Father's  phone number *
Father's  employer and phone number *
Emergency Numbers (Please include all emergency contacts) *
Your child will be receiving a snack.  Please list any known food allergies your child may have and list any health condition we should be aware of.  (ie: Asthma, other allergies): *
I hereby authorize the staff of the Pierce After School & Safety Program to secure and sign for emergency medical care for my child at my expense, when necessary.In case of an emergency injury or illness, I authorize the Program to call the paramedics.  As legal guardian of the above listed student, a minor, I authorize the school representative designee to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered upon the advice of any licensed physician and or dentist. *
Describe below how your child will depart from the facility on a daily basis: (i.e.: picked up by parent/guardian or authorized person, bicycling, walking, etc.) *
Please List any persons authorized to take your child from the facility on a daily basis *
My child may watch PG-13 Movies *
If you would like your child to walk home please list the time you would like them to leave. Please note that during daylight saving time, students will not be permitted to walk after 4:30pm.
By typing your name below, you acknowledge you have read and understand the handbook and that the program is not responsible for personal items. *
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