After School Enrichment Program Enrollment Form Please take your time and complete this form. Step 1 of 5 20% Student InformationHow many students*0123Student 1Name* First Last Gender* Male Female Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School/Location* Grade*Pre-KK123456789101112Year*20202019201820172016Semester*SpringSummerFallStudent 2Name* First Last Gender* Male Female Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School/Location of Program* Grade*Pre-KK123456789101112Year*2020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993Semester*SpringSummerFallStudent 3Name* First Last Gender* Male Female Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School/Location of Program* Grade*Pre-KK123456789101112Year*20212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993Semester*SpringSummerFall Parent/Guardian informationParent/Guardian Name* First Last Phone*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Alt PhoneEmployer Work Phone Emergency Contact InformationEnter the names of those authrozied to pick up your child.Contact 1 Name First Last Contact 1 PhoneContact 1 Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact 2 Name First Last Contact 2 PhoneContact 1 Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Permission & ReleasesI give AKCCL's authorized personnel permission to transport my child, in the event that I or the contact(s) list above is unavailable or unable to be contacted, and my child requires transportation. I give my child permission to participate in all physical education activities. I consent to the use of any photograph of my child/dependent/self, and/or any copies of this photograph in any editorial and/or promotional material produced and/or published. **In case of an accident, serious injury, or illness, the program will contact you. In the event that we cannot reach you, your signature below authorizes officials of the AKCCL to take whatever action is deemed necessary, in their judgment, for the health and safety or your child. It is given to provide consent for medical care.** Permission Granted* Yes Health InfomationMedical ConsiderationsPlease indicate if your child has any specific medical considerations on the lines provided. ( Allergies, food, medication, etc. ) Select Service TypeAftercare OnlyBefore Care OnlyBefore & AftercareSummer EnrichmentStart Date Registration CostRegistration is twenty-five dollar ($25.00) required each semester per student. Payment Due Price: $0.00 Signature/Authorization* My signature confirms authorization of payment and indicates that I have provided the information above to the best of my ability.