After Care Application
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Email *
First Name of Student *
Last Name of Student *
Grade *
Class or teacher

Parent #1 name *
Parent phone number *
Parent #2 name
Parent phone number
Emergency contact #1 name & phone number *
Emergency contact #2 name & phone number *
Emergency contact #3 name & phone number
By signing this application, I acknowledge that I am responsible for paying the monthly fee for my child(ren) by the 1st of each month for the following month in order for my child(ren) to attend the program.  If I have not paid my child will not be permitted to attend.
Type your name below acknowledging the above statement. *
A copy of your responses will be emailed to the address you provided.
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