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After School Program

2024-25 After School Program Registration Form

Student Information

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Street Address

Answer required for "Street Address"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

If yes, please indicate:

Answer required for "If yes, please indicate:"

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 for "Indicate Your Needs for After School Care:"

Monday

Tuesday

Wednesday

Thursday

Friday

As Needed

Parent Information

Parent / Guardian 1 First Name*

Answer required for "Parent / Guardian 1 First Name"

Parent / Guardian 1 Last Name*

Answer required for "Parent / Guardian 1 Last Name"

Parent / Guardian 1 Email*

Answer required for "Parent / Guardian 1 Email"

Parent / Guardian 1 Phone*

Number Required

Parent / Guardian 2 First Name

Answer required for "Parent / Guardian 2 First Name"

Parent / Guardian 2 Last Name

Answer required for "Parent / Guardian 2 Last Name"

Parent / Guardian 2 Email

Answer required for "Parent / Guardian 2 Email"

Parent / Guardian 2 Phone

Number Required

Who will be picking up your child?*

Answer required for "Who will be picking up your child?"

Insurance Information

Doctor's Name*

Answer required for "Doctor's Name"

Doctor's Phone Number*

Answer required for "Doctor's Phone Number"

Insurance Carrier*

Answer required for "Insurance Carrier"

ID Number*

Answer required for "ID Number"

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

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"