Afterschool Student Registration Form

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Whidby Afterschool Registration Form

Whidby is currently accepting applications for the FALL 2019 after school program. The FALL program will begin TUESDAY, SEPTEMBER 3, 2019 and will end THURSDAY, DECEMBER 19, 2019. Due to overwhelming request from parents the program hours have been extended to 2:50 – 5:45 p.m. Monday - Friday with the exception of holidays, early release days, district and state testing days and inclement weather days when school is canceled. There will be a $200.00 application fee per student per semester (Fall/Spring). Fees will be collected by the front office staff beginning Monday, August 12, 2019. Only 75 students can be serviced, so complete your application as early as possible to be considered for acceptance.

1.	Student First Name*

2.	Student Last Name*

3.	Gender* Select at least 0 and no more than 0.
	Male Female

4.	Grade*

5.	Date of Birth*
	mm/dd/yyyy

6.	Street Address*

7.	City*

8.	State*

9.	Parent/Guardian Name*

10.	Main Contact Number*

11.	Email Address*

12.	Ethnicity/Race Select at least 1 and no more than 2.
	Hispanic Black/African American White Asian Other Other, please specify

13.

Who is authorized to pick up your child?*

	First and Last Name	Telephone Number	Address	Relationship
1.
2.
3.
4.

14.

Emergency Contact Information*

	First and Last Name	Telephone Number	Address	Relationship
1.
2.
3.
4.
5.

15.

Please provide the names of other children applying for the program.

	First and Last Name	Grade
1.
2.
3.
4.
5.

16.	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

17.	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

18.	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. *