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*

6.	Date of Birth*
	mm/dd/yyyy

7.	Street Address*

8.	City*

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. *