Zervas After School Program, Inc. Online Registration

Registration

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Welcome to Zervas After School Program, Inc.! 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 Info (Not Contact #1 or #2)*

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*

Who is your employer?

Employer*

Employer Phone*

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Grade Level*

Transportation*

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

Immunizations YN*

Immunization Notes*

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*

Cell #

Additional Info

Grade Level*

Transportation*

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

Immunizations YN*

Immunization Notes*

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*

Cell #

Additional Info

Grade Level*

Transportation*

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

Immunizations YN*

Immunization Notes*

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*

Cell #

Additional Info

Grade Level*

Transportation*

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

Immunizations YN*

Immunization Notes*

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*

Cell #

Additional Info

Grade Level*

Transportation*

Disabilities (Leave blank if NONE)*

Special Needs (Leave blank if NONE)*

Allergies (Leave blank if NONE)*

Medications (Leave blank if NONE)*

Primary Doctor*

Immunizations YN*

Immunization Notes*

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

Enroll in Classes

Select Class *

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

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?

Who is your employer?

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

Required Policies

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