Admission Application

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After School Enrichment Program (ASEP) Enrollment Application

Child's Name
Gender
Date of Birth

Parents’ Information:

Name(Father)
Date of Birth(DOB)
Phone(Home)
Phone(Cell)
Address
Work Hours
Company
Phone
Name(Mother)
Date of Birth(DOB)
Phone(Home)
Phone(Cell)
Work Hours
Company
Phone

Emergency Contact:

(Persons to be contacted if parents cannot be reached)

Name
Relation
Phone
Name
Relation
Phone

Special Needs:

Allergies or Food Restrictions? Yes / No If yes, please list:(more details)
0 /
Prescribed Medications? Yes / No If yes, please list: (You must also submit a completed medical form along with any medication to the Program)(more details)
0 /
Mobility Limitations? Yes / No If yes, please describe:(more details)
0 /
Other physical or mental needs requiring staff attention? Yes / No If yes, please describe:(more details)
0 /

Please initial indicating that all known special needs and restrictions of your child(ren) to be enrolled have been disclosed.

In case of emergency, I give my permission for my child to be taken for emergency treatment.

Media Release:

I hereby give permission and authorize the use of still photographs and video images in which my child(ren) may appear for purposes of employee training, and/or marketing.

Pick Up:

Generally what time should we expect your child to depart? This is very important in planning for adequate staff to care for your child(ren):

Mon
Tue
Wed
Thur
Fri

Alternate Pick-up:

(Include the names of additional adults not already listed above)

Name
Relation
Phone
  • All authorized alternate pick-up information will be kept updated by parents/guardians.
  • All alternate authorized pick-up must be 18 or older.
  • All alternate authorized pick up must present a carpool tag or valid government-issued identification.
  • I understand that Enrichment staff will ONLY release child(ren) to parents/guardians or adults listed above.
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