After Care Sign-Up

Child's Name

Grade

Address

City

State

Zip Code

Birthdate

Church

Father's First Name

Father's Last Name

Mother's First Name

Mother's Last Name

Parent's Email

Instructions on who is to pick up the child

Emergency Contact Phone

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

Any restrictions pertaining to activities or food?

Any allergies?

Special interests or hobbies?

Other helpful information?

I AGREE

I agree to all of the above.