Brookline After School Program Online Registration

Registration

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Welcome to Brookline Afterschool Program! Please complete the following registration form.

* 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

Emergency Contact & phone no#nfo (Other than Parents)*

Insurance Contact Phone Number*

Photo Release Y/N

Child's Schedule*

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*

Who is your employer?

Employer*

Employer Phone*

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class *

Add Another Student