The GLOBE Academy ECP (Extended Care Program) Online Registration

Registration

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Welcome to online registration for the The GLOBE Academy ECP (Extended Care Program) which is comprised of BeforeCare, AfterCare, and Daily Drop-In. In this registration system you can enroll, add students, update contact/payment info, and view policies. After your enrollment, GLOBE will add any applicable sibling discounts and then process your payment for you. Please be sure to check your account and email confirmations for accuracy. Visit www.theglobeacademy.org for more ECP info.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Name & Phone of Local Adult (other than parent) to Contact in Emergency*

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work # *

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name*

Last Name*

Type*

How can we contact you?

Home Phone

Work #

Cell # *

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Gender Identity*

Birth Date*

Additional Info

T-Shirt Size

Grade Level*

Special needs/strengths/sensitivities (physical, mental, emotional)?

Special Needs*

Allergies (please enter "None" if not applicable)*

Medications (Leave blank if NONE)

Primary Doctor

You can search for specific class names or days of the week by typing letters in the fields at the top of each column. After your enrollment, GLOBE will add any applicable sibling discounts and then process your payment for you

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity*

Birth Date*

Additional Info

T-Shirt Size

Grade Level*

Special needs/strengths/sensitivities (physical, mental, emotional)?

Special Needs*

Allergies (please enter "None" if not applicable)*

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity*

Birth Date*

Additional Info

T-Shirt Size

Grade Level*

Special needs/strengths/sensitivities (physical, mental, emotional)?

Special Needs*

Allergies (please enter "None" if not applicable)*

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity*

Birth Date*

Additional Info

T-Shirt Size

Grade Level*

Special needs/strengths/sensitivities (physical, mental, emotional)?

Special Needs*

Allergies (please enter "None" if not applicable)*

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Gender Identity*

Birth Date*

Additional Info

T-Shirt Size

Grade Level*

Special needs/strengths/sensitivities (physical, mental, emotional)?

Special Needs*

Allergies (please enter "None" if not applicable)*

Medications (Leave blank if NONE)

Primary Doctor

Enroll in Classes

Select Class *

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Who is your employer?

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

eCheck/Bank Draft

Required Policies

(Show-Hide Details)