After Care Sign-Up

After Care Sign-Up

Child's Name

First

Last

Grade

Address

City

State/Province

Zip/Postal

Country

Birth Date

Church

Father's Name

First

Last

Instructions on who is to pick up the child:

Emergency Contact:

First

Last

Mother's Name

First

Last

Emergency Contact Phone

COST: $8.00 per hour | 3:30 pm – 6:00 pm

Any restrictions pertaining to activities or food?

Any allergies?

(List all known allergies)

Special interests or hobbies?

Other helpful information?

Signature

Date of Signature

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