AFTER SCHOOL REGISTRATION FORM

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Policy: Parents or Guardian must sign on the form and all the information provided are confidential and secured.

Child Information

First name

Last name

Date of Birth

Gender

Grade

Name of School

Teacher Contact

Parent or Guardian

First name

Lastname

Phone

Email

Address

City

state

zip

Emergency Contact

Name

Phone

Email

Address

City

state

zip

I give my children permission

TO attend summer

TO attend summer To travel with staff and volunteer from shalom community impact center To be including in photos, website of shalom taken during the program

Parent or Guardian Signature

Upload a scaned signature here