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Program Registration Afterschool New
Please complete the form below and we will contact you soon.
*
These fields are required.
First Name:
*
Last Name:
*
Returning PT Participant:
*
--None--
No
Yes
Phone:
*
Street Address:
*
City:
*
State/Province:
*
Zip:
*
Birthdate (MM/DD/YYYY):
*
Participant Age Group:
*
--None--
0-11
12-15
16-18
Gender:
*
--None--
Female
Male
School:
*
Grade (as of coming Fall semester):
*
--None--
01
02
03
04
05
06
07
08
09
10
11
12
Ethnicity:
*
--None--
Hispanic or Latino
Not Hispanic or Latino
Race:
*
--None--
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Two or More Races
Primary Language:
*
--None--
English
Spanish
Chinese
French
Vietnamese
German
Korean
Russian
Arabic
Italian
Portuguese
Polish
Hindi
Japanese
Persian
Armenian
Hebrew
Child qualifies for gov't assistance or free/reduced lunch program:
*
--None--
No
Yes
Household Monthly Income ( 1500.00 format, no $ and no comma):
*
Number of members in household:
*
Parent/Guardian First Name:
*
Parent/Guardian Last Name:
*
Parent/Guardian Email:
Parent/Guardian Phone:
*
Phone Type:
*
--None--
Mobile
Home
Work
How does the child leave school?:
*
--None--
Pick-up
Walk Home
List names of adults, other than parent or guardian, who have permission to pick up this child:
*
Emergency Contact 1:
*
Emergency Contact 1 Relation:
*
Emergency Contact 1 Email:
Emergency Contact 1 Mobile Phone:
*
Emergency Contact 1 Home Phone:
Emergency Contact 2:
*
Emergency Contact 2 Email:
Emergency Contact 2 Home Phone:
Emergency Contact 2 Mobile Phone:
*
Emergency Contact 2 Relation:
*
Medical Information:
*
Food Allergies:
*
--None--
Yes
No
Food Allergy Details:
Medicine Allergies:
*
--None--
Yes
No
Medicine Allergy Details:
Program Location:
*
--None--
Casa Linda UMC Elem Gr 1-5
Chapel Hill UMC Elem Gr 1-5
Christ's Foundry Elem Gr 1-5
Cockrell Hill UMC Elem Gr 1-5
Elmwood UMC Elem Gr 1-5
Grace UMC Elem Gr 1-5
Munger Place UMC Elem Gr 1-5
Pleasant Mound Urban Park UMC Elem Gr 1-5
Walnut Hill UMC Elem Gr 1-5
Waples Memorial UMC Elem Gr 1-5
Registration Fee Paid:
*
--None--
In Full $20
Partial
Waived
Participant PTDID (6 digits include leading zeros):
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