Afterschool Student Registration Form
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Whidby 21st Century Registration Form
Whidby is currently accepting applications for the Texas ACE, Afterschool Center of Education, Program. The afterschool program will begin Tuesday, September 6, 2022, and will end Thursday, December 22, 2022. The hours of operation will be from immediately following the regular school day until 6:00 p.m. except for holidays, early release days, district and state holidays days and inclement weather days when school is canceled. The program is FREE of charge for Whidby students. Please complete the application to register your child(ren) for the program. ONE FORM SHOULD BE COMPLETED FOR EACH CHILD.
1.
Student First Name
*
2.
Student Last Name
*
3.
Gender
*
Select at least 0 and no more than 0.
Male
Female
4.
What is your child's student number WITHOUT the leading S (S number)?
(%99,999,999)
5.
Grade
*
--Please Select--
Pre-K
Kinder
1st
2nd
3rd
4th
5th
6.
Date of Birth
*
mm/dd/yyyy
7.
Street Address
*
8.
City
*
9.
What is your relationship to the child?
*
Select at least 1 and no more than 2.
Mother
Father
Grandparent
Aunt or Uncle
Other (foster parent, guardian, sister, brother...)
Other, please specify
10.
State
*
11.
Parent/Guardian Name
*
12.
Main Contact Number
*
13.
Email Address
*
14.
Ethnicity/Race
Select at least 1 and no more than 2.
Hispanic
Black/African American
White
Asian
Other
Other, please specify
15.
Who is authorized to pick up your child?
*
First and Last Name
Telephone Number
Address
Relationship
1.
2.
3.
4.
16.
Emergency Contact Information
*
First and Last Name
Telephone Number
Address
Relationship
1.
2.
3.
4.
5.
17.
Please provide the names of other children applying for the program.
First and Last Name
Grade
1.
2.
3.
4.
5.
18.
How will the student get home?
*
Select at least 1 and no more than 2.
Walk
Picked Up
City Bus
Daycare Bus
Other
Other, please specify
19.
Is there any medical reason why your child should not participate in certain physical activities? If YES, list why and provide the names of any medications.
No
20.
I hereby give permission for the participant(s) listed on this form to take part in the Whidby Afterschool Program activities, which may include off-site events, academic assistance, and recreational programs. If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the participant and will call, if necessary, a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred. (Optional – Please check box for consent) I also give my consent for Whidby to take the participant’s photograph during program activities, to be used for education and public relations purposes.
*
--Please Select--
Yes
No