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After School Enrichment Program

Online Registration Form - 1 per Child
Site/Program Information:
Site Choice*:
Program(s) Choice*: Before School
After School
        -- OR --
Workdays/Early Release
 
Student Information:
Child's Name*:
  (Last) (First) (Middle / Nickname)
Child's Address*:
  (Street) (City) (Zip)

Child Lives With*:
Age*:
DOB*:
Select a date from the calendar.
Gender*:
Fall 2017 Grade*:
Daytime School*:
 
Parent/Guardian Information:

       Parent 1       

Name*: Relationship*:   
Address*: Home Phone*:
Place of Employment*: Mobile Phone*:
Email*: Work Phone*:
 
 

       Parent 2       

Name: Relationship:   
Address: Home Phone:
Place of Employment:   Mobile Phone:  
Email: Work Phone:
 
Fees will be paid by*:



https://webpay.easydraft.com/CS/CMS-ASEP
 
Persons (age 16 or older) authorized to pick up child other than parents:
  Name  Relationship  Address  Phone 
1.
2.
3.
 
Information about your child*:
List any allergies and the symptoms and type of response for these health care needs or concerns.
Please add NA for Not Applicable.
You have used 0 of 350 total characters. 
 
List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns.
Please add NA for Not Applicable.
You have used 0 of 350 total characters. 
 
List any particular fears, unique behavior characteristics or special needs the child has.
Please add NA for Not Applicable.
You have used 0 of 350 total characters. 
 
List any types of medication taken for health care needs.
Please add NA for Not Applicable.
You have used 0 of 350 total characters. 
 
Share any other information that has a direct bearing on assuring safe medical treatment for your child.
Please add NA for Not Applicable.
You have used 0 of 350 total characters. 
 
Insurance Information:
Insurance is required for all children enrolled in the After School Enrichment Program. You may choose to purchase student accident insurance in the fall at the school, medical insurance or your own, or both. Please indicate insurance coverage for your child. (*You must select one option)
Insurance Company: Policy Number:
 
Emergency Care Information:
Child's Doctor Name*: Phone*:
Address*: Hospital Preference*:
If parent/guardian cannot be reached, call
Name*: Phone*: Relationship*:
 
Please note all information in the following section is required and must be completed.

  Agreement 1  

I the undersigned parent/guardian of , agree that the ASEP Site Coordinator may authorize the physician of her/his choice to provide emergency care in the event that neither I nor a family physician can be contacted immediately.
Date:
 

  Agreement 2  

I the undersigned parent/guardian of , do hereby state that I have read and received a copy of the Discipline and Behavior Management Policy and that the Site Coordinator (or other designated staff member) has discussed any questions I had about the Discipline and Behavior Management Policy with me.
Date:
 

  Agreement 3  

I the undersigned parent/guardian of , do hereby state that I have read understand the ASEP Family Guidelines, the NC Summary of Childcare Laws and that the Site Coordinator (or other designated staff member) has discussed any questions I had about the ASEP Family Guidelines and the Summary of Childcare Laws with me.
Date:
 
 
* Indicates Required Information