After School Only – Headwaters Academy

STUDENT INFORMATION:

Child's Name*

First Middle Last Goes By

Grade Enrolled:*

After-school program is for K-5th grades and will run from 3p-6p Mon to Fri. Monthly fee will be $210 per month per child.

Birth Date*

Gender:*

Male
Female

Home Address:*

Street Address City State ZIP Code

EMERGENCY CONTACT INFORMATION:

1st Emergency Contact Name*

First Last

1st Emergency Contact Relationship*

1st Emergency Contact Phone*

2nd Emergeny Contact Name*

First Last

2nd Emergency Contact Relationship*

2nd Emergency Contact Phone*

FAMILY INFORMATION:

Father or Guardian Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Mobile Phone*

Email*

Enter Email Confirm Email

Occupation:*

Employer:*

Name of church where you are a member:*

Attending Regularly?*

Yes
No

Church City/State*

City State

Mother or Guardian Name*

First Last

Address:*

Street Address City State ZIP Code

Mobile Phone*

Email*

Enter Email Confirm Email

Occupation:*

Employer:*

Name of church where you are a member:*

Attending Regularly?*

Yes
No

Church Address*

City State

Parent's Marital Status:*

Child resides with:*

Number of children living in the home:*

Are there any custodial difficulties?*

SCHOOL INFORMATION

Has the child ever been suspended?*

Yes
No

If yes, please state reason:

Has the child ever had any difficulty with the Civil Authorities?*

Yes
No

If yes, please give the details and reason for the difficulties:

Has the child experienced any learning difficulties or been diagnosed as ADD/ADHD?*

Yes
No

If yes, please explain:

Agreement with Fees and Policies

Links to documents and handbooks where applicable, are included at the top of this form.

We agree to pay the $25 per child registration fee.*

Fee due with submission of this form (see details at the top of this form for payment options.) Registration is not complete until $25 fee is submitted.

Yes

We agree to commit to paying Headwaters After School fees on the first Monday of every Month.*

Monthly Fee is $210. Partial months will be prorated if there are less than 18 school days in the month.

Yes

We understand that images of our child may be captured and used through video, photo and digital camera, to be used solely for the purposes of promotional material and publications, and we waive any rights of compensation or ownership thereto.*

Yes

Upon application approval and we will submit the required additional Transportation Permission & Medical and Liability forms*

Forms must be submitted prior to participating in the After School Program

Yes

We have received and read the Parent-Child Handbook V3.0. We understand and will abide by the policies as presented in the document.*

Yes

We confirm that all the information submitted in this form is accurate and truthful*

Yes

Date*

Signature of Father or Guardian*

Signature of Mother or Guardian*