Student Name *

First Name

Last Name

Program Options *

Before Care Only

After Care Only

Before and After Care

Mother's Name

First Name

Last Name

Mother's Phone

(###)

###

####

Father's Name

First Name

Last Name

Father's Phone

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Before/After Care Payment Options *

Monthly Payments must be made on or before the first of each month. Weekly Payments must be made each Friday in advance.

Monthly ($100 per Student)

Weekly ($35 per Student)

Daily ($11 a Day per Student)

Program Options *

Before Care

After Care

Before and After Care