WCPSS Before and After
School Programs 2009-2010
After School Program Student Application
-
There is a $15.00
registration fee per applicant
Please make check payable Holly Ridge Elementary
Student’s
Full Name: _______________________________________________________________________
Name
the Child Is To Be Called:
______________________________________________________________
Address: _________________________________________________________________________________
___________________________________________________________________________________
Home
Phone: ______________________________
Date of Birth: _______________ Age: _____________
Monthly Fee: $123.75 per applicant
Grade:
________________ Homeroom Teacher’s Name: __________________________________________
Parents/Guardians:
_________________________________________________________________________
Father’s/Guardian’s Place of Employment: ______________________________________________________
Work
Phone:____________________________ Cell
Phone ____________________________________
Mother’s/Guardian’s Place of Employment: ______________________________________________________
Work
Phone: ___________________________ Cell
Phone _____________________________________
In case of emergency, notify the following person(s)
if parents/guardians cannot be reached:
Name:
_________________________________ Phone:
_________________ Relationship: _______________
Name:
_________________________________ Phone:
_________________ Relationship: _______________
Names of Individuals to Whom the Program Staff May
Release the Child as Authorized by the Person Who Signs the Application:
_________________________________________________ _____________________________________
_________________________________________
_____________________________________
Student’s Physician
_____________________________ Phone
_____________________________________
Student’s Dentist
_______________________________ Phone
_____________________________________
Hospital Preference: first choice____________________________ second
choice__________________________
PLEASE FILL OUT THE BACK and SIGN
After School Program Student Application continued…
Does your student have allergies or chronic
illnesses? If yes what are they?
____________________________________________________________________________________
Please give any other information that you would
like the After-School Program staff to know about your student (special
interests, fears, behaviors, custody arrangements, etc.).
_____________________________________________________________________________________
_____________________________________________________________________________________
In case of emergency, I authorize the After-School
Program staff to obtain medical attention for my student in the event that I
cannot be contacted immediately.
My signature indicates that
I have read and understand the procedures for the After-School Program.
__________________________________________Date: __________________________
Parent Signature