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Enrollment Form for 2023-2024 School Year

Tell us about your child

Child's Name *

First

Last

Grade for 2023-2024 *

PreK
Kinder
1st
2nd
3rd
4th
5th

Homeroom Teacher (If Known)

Date of Birth *

Child's Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Child's Home Phone *

Child's Doctor *

Child's Doctor Phone and Address *

Child's Insurance Carrier/Plan #/ID #

Allergies *

Please list any and all allergies. Please explain how your child reacts and how it is treated. If none, please type none.

Medical Conditions *

Please list and and all medical conditions. If none, please type none.

Medications *

Please list any medications your child takes. If none, please type none.

Behavioral Issues *

Please list any behavioral issues. If none, please type none.

Guardian Information and Authorization to Pick Up

Guardian #1 Name *

First

Last

Guardian #1 Phone *

Guardian #1 Email *

Email

Confirm Email

Does Guardian #1 have a different address? *

YES
NO

Guardian #1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Guardian #2 Name

First

Last

Guardian #2 Phone

Guardian #2 Email

Email

Confirm Email

Does Guardian #2 have a different address?

YES
NO

Guardian #2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Other People Authorized to Pick-Up and Phone Numbers

May we contact the people above in an emergency?

YES
NO

Authorizations

Photo Release *

YES
NO

We take pictures and video of activities in Red After School Care. The photos/videos are used for bulletin board decorations, advertising the program, and sharing with families in the program. May we use your child's picture?

Authorization to seek medical care and/or transport your child to a medical facility. *

I AUTHORIZE Red After School Care program to seek medical care for my child and/or transport them to a medical facility.
I DO NOT AUTHORIZE Red After School Care program to seek medical care for my child and/or transport them to a medical facility.

Agreement to Policies and Procedures *

I agree to the Policies and Procedures
I DO NOT agree to the Policies and Procedure

Our program's policies and procedures can be found here: https://redafterschoolcare.com/policies-and-procedures/ In order to be in the program you must agree to the policies and procedures.

Sign this Form *

By typing your name above, you are certifying that all the information is correct to the best of your knowledge.

Today's Date *

Tell us about your child

Guardian Information and Authorization to Pick Up

Authorizations

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