This is for aftercare from 3:00-5:00. When enrolling please state the days or week you are enrolling your child(ren) for in the Other Questions/Comments section. This form only enrolls you for weekly, so we will manually adjust it before your card is charged. If you have any questions, you can call us or put them in the Additional Information section, and we will contact you immediately. $100/Weekly or $20/Daily
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
Address: *
City: * State: * Zip: *
Students entered below will be added to your family's account
Additional Information:
Other Questions/Comments:
Credit Card Verification:
Card Number: *  
Name as it appears on card: *
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*