PS 261 PTA Afterschool Online Registration

Welcome to PS 261 PTA Afterschool. Please complete the following registration form.

* denotes required fields

Family Information

Family / Account Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

**NOT Authorized to Pick Up**

Contact #1

Parent/Contact #1 First Name*

Last Name *

Relationship to student*

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

Contact #2

Parent/Contact #2 First Name*

Last Name*

Relationship to Student*

How can we contact you?

Home Phone

Work #

Cell # *

Email* (Emails are kept confidential)

Confirm Email*

Student #1

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

Grade Level*

Does your child have 504 accommodation or an IEP?*

Would you like discuss your child's IEP or medical requirements with the Director?*

Allergies*

Medications*

Primary Doctor (name/#)*

Classroom

Pronouns

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

Grade Level*

Does your child have 504 accommodation or an IEP?*

Would you like discuss your child's IEP or medical requirements with the Director?*

Allergies*

Medications*

Primary Doctor (name/#)*

Classroom

Pronouns

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

Grade Level*

Does your child have 504 accommodation or an IEP?*

Would you like discuss your child's IEP or medical requirements with the Director?*

Allergies*

Medications*

Primary Doctor (name/#)*

Classroom

Pronouns

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

Grade Level*

Does your child have 504 accommodation or an IEP?*

Would you like discuss your child's IEP or medical requirements with the Director?*

Allergies*

Medications*

Primary Doctor (name/#)*

Classroom

Pronouns

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender

Birth Date*

Additional Info

Grade Level*

Does your child have 504 accommodation or an IEP?*

Would you like discuss your child's IEP or medical requirements with the Director?*

Allergies*

Medications*

Primary Doctor (name/#)*

Classroom

Pronouns

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Please fill out CREDIT CARD Payment Method

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

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

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)