After School Registration Form

Step 1 of 4

General Information

Name(Required)
Birth Date(Required)
5-days or 3-days?(Required)
(If only 3 days) Please select which days they will attend:
Address(Required)

Parent/Guardian Information

Parent/Guardian 1 Name(Required)
Parent/Guardian 1 Home Address(Required)
Parent/Guardian 2 Name
Parent/Guardian 2 Home Address

Emergency Contact Information

Emergency Contact Name
Is This Person Authorized To Take The Child From FAC?
Emergency Contact Address

List All Other Adults Who Are Authorized To Take Child From FAC:

Name
Name
Name