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After School Program

2024-25 After School Program Registration Form

Student Information

First Name*

Answer Required

Last Name*

Answer Required

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

If yes, please indicate:

Answer Required

Indicate Your Needs for After School Care:*

If you are signing up for the "As Needed" basis, you must indicate this selection in Pick-up Patrol no later than 10:00AM on the day that care is needed.

Answer Required

Monday

Tuesday

Wednesday

Thursday

Friday

As Needed

Parent Information

Parent / Guardian 1 First Name*

Answer Required

Parent / Guardian 1 Last Name*

Answer Required

Parent / Guardian 1 Email*

Answer Required

Parent / Guardian 1 Phone*

Number Required

Parent / Guardian 2 First Name

Answer Required

Parent / Guardian 2 Last Name

Answer Required

Parent / Guardian 2 Email

Answer Required

Parent / Guardian 2 Phone

Number Required

Who will be picking up your child?*

Answer Required

Insurance Information

Doctor's Name*

Answer Required

Doctor's Phone Number*

Answer Required

Insurance Carrier*

Answer Required

ID Number*

Answer Required

I authorize St. Gregory the Great to seek the necessary medical care in case of an emergency.*

Signature Required

Confirmation Email

Confirmation Email *

Email Required