We are now registering for September 2008 AfterCARES
Fields displayed in bold are required.
Student Information
First Name:
Last Name:
Age:
Grade:
School Child Attends:
Student ID Number:
   
Parent/Guradian Information
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
ZIP/Postal Code:
Home Phone:
Work Phone:
Email Address:
   
Program Information
My child is interested in the following t ypes of programs:
Tutoring
Test Prep
Art
Computers
Sports		 Drama
Lifeskills
Youth Employement
Other:
   
Transportation Information
At the end of the program day, my child will:
Walk Home
Take SEPTA
Be picked up by:
 
Emergency Contact Information
Name:
Phone Number:
Relationship:
   
Name:
Phone Number:
Relationship:
   
Comments:
 
By competing this form, you have read and understand the programs that you have registered your child for and agree to pay all fees. You also understand that it is your responsibility to arrange for transportation to and from the programs.
Verification:
Please retype the letters and numbers from the image into the box below:
 

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