St. Mary’s Academy After-School Program

Registration Form

Child's Name: __________________________________ Birth Date: ____________________

Mother's Name: _____________________________ Occupation: ________________________

Address: __________________________________ Home Phone:_________Work:__________

Father's Name: ______________________________ Occupation: ________________________

Address: __________________________________ Home Phone:_________Work:__________

Name of adults authorized to pick up the child (other than the names written above):

1. __________________________________ 2.__________________________________

3. __________________________________ 4.__________________________________

Does your child have allergies? Yes No

(If yes, please specify): _________________________________________________________

Is there anything special you feel we should know about your child?

_________________________________________________________________________

Names of brothers and sisters:

1. __________________________________ 2.__________________________________

3. __________________________________ 4.__________________________________

The cost is $5 per session (no matter how long you stay in aftercare) I would be able to help out with

Aftercare on the following days (3-5:30 PM):

Mon ____ Tues _____ Wed _____ Thurs _____ Fri _____

___________________________________________ ____________________________

Parent Signature / Date