Wake County Public Schools 2009-10
After School Program Student
Application
Wednesdays-Only $30.25 per child per month
PLUS
a $15.00 registration fee per
applicant. Please make check payable to Holly
Ridge Elementary.
Student’s
Full Name: ____________________________________________________________________
Name
the Child Is To Be Called:
___________________________________________________________
Address:
______________________________________________________________________________
________________________________________________________________________________
Home
Phone: ____________________________
Date of Birth: _______________ Age: ____________
Grade:
________________ Homeroom Teacher’s Name: _______________________________________
Parents/Guardians:
______________________________________________________________________
Father’s/Guardian’s Place of Employment: ___________________________________________________
Work
Phone:__________________________ Cell Phone: ___________________________________
Mother’s/Guardian’s Place of Employment: ___________________________________________________
Work
Phone:__________________________ Cell Phone:
___________________________________
In case of emergency, notify the following person(s)
if parents/guardians cannot be reached:
Name:
____________________________ Phone:
___________________ Relationship: _______________
Name:
____________________________ Phone:
___________________ Relationship: _______________
Names of Individuals to Whom the Program Staff May
Release the Child as Authorized by the Person Who Signs the Application:
_________________________________________ _________________________________________
______________________________________
_________________________________________
Student’s Physician ___________________________ Phone _____________________________________
Student’s Dentist _____________________________
Phone ____________________________________
Hospital Preference: first choice_________________________ second
choice__________________________
Does your student have allergies or chronic
illnesses? If yes what are they?
____________________________________________________________________________________
Please give any other information that you would
like the After-School Program staff to know about your student (special
interests, fears, behaviors, custody arrangements, etc.).
_____________________________________________________________________________________
_____________________________________________________________________________________
In case of emergency, I authorize the After-School
Program staff to obtain medical attention for my student in the event that I
cannot be contacted immediately.
My signature indicates that
I have read and understand the procedures for the After-School Program.
__________________________________________Date: __________________________
Parent Signature