Czech Point After School Program 
$35/Student every 9 weeks*
STUDENTS IN GRADES K-5 ONLY
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Email *
Student's First and Last Name *
Date of Birth *
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Student's Grade *
Student's Homeroom *
Siblings also in the program  *
Guardian 1 First and Last name and Cell number *
Guardian 2  First and Last name an Cell number *
Emergency Contact 1  First and Last name and Cell number *
Extra Pickup Person 1  First and Last name and Cell number
Does your student wear glasses, hearing aides, ect.? *
Does your child have special medical needs *
If yes, please explain: 
Is your child on any medication?  *
If yes, please list the type of medication and dosage
Please list any of your student's know allergies here *
Photo/Video Release: By selecting below, Guardian 1 agrees to allow photos and video to be taken of my child during events and performances given by the students.  *
Required
Please type in the legal guardian's name below. This form must be signed in person during pick up time at the after school program.

The Legal Guardian of the student listed above authorizes Czech Point staff to seek medical attention for the student, be it medical, dental, or surgical in case of emergency. Parent's will be notified in such situations. Please type in the legal guardian's name below. This form must be signed in person before the student may begin the program.  *
A copy of your responses will be emailed to the address you provided.
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