Afterschool Enrollment Application

Please fill out ALL of the required information.

Please note that if you do not register your child within 24 hours of the day you would like him/her to start they will not be able to attend program until the following day.

Family Information

Guardian 1

Guardian 1 Name

Mr.Ms.Mrs.

First Name

Last Name

Home Phone

Work Phone

Cell Phone

Email

Street

City

State

Zip

Guardian 2

Guardian 2 Name

Mr.Ms.Mrs.

First Name

Last Name

Home Phone

Work Phone

Cell Phone

Email

Street

City

State

Zip

Emergency Contact

Emergency Contact
In case of emergency, who else may we contact (other than a parent)?

Emergency Phone

Their relationship to your child

Child Information

Child 1

1st Child's First Name

Last Name

Date of Birth
mm/dd/yyyy

Age

Gender

MaleFemale

Teacher

Grade

Child 2

2nd Child's First Name

Last Name

Date of Birth
mm/dd/yyyy

Age

Gender

MaleFemale

Teacher

Grade

Medical Information

Does your child have any alergies?

YesNo

If yes, please explain

Does your child have asthma?

YesNo

Does your child have any other medical conditions we should know about?

YesNo

If yes, please explain

Is there anything else we should know about your child in order to better assist us with his/her care?

YesNo

Please explain

School

Daily Enrollment Information

Please indicate the days you expect your child to attend most frequently.
Please note that the activities may be subject to change. You can enroll in no fewer than three days per week.

MondayTuesdayWednesdayThursdayFridayDrop-in Only*

24 hour notice
Please note that if you do not register your child within 24 hours of the day you would like him/her to start they will not be able to attend program until the following day.

or Reset

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20 Jay St., Suite 314 • Brooklyn, NY 11201
Tel: 646-519-5050/ Fax: 646-217-3147