Registration
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Welcome to PS10 PTA Extended Day Program!
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denotes required fields
Family Information
Family Last Name
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Where do you live?
Home Address
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City
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New York
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
PR
VI
Zip
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Primary Phone
Additional Info
Emergency Contact Info Name and Cell Phone(Not Contact #1 or #2)
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Contact #1
Contact #1 First Name
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Last Name
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Type
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Caregiver
Father
Guardian
Mother
Parent
Self
How Can We Contact You?
Home Phone
Work #
Cell #
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Portal Access (your email is your login)
Email
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(Emails are kept confidential)
Confirm Email
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Portal Account Password
Confirm Portal Account Password
Contact #2
Contact #2 First Name
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Last Name
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Type
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Caregiver
Father
Guardian
Mother
Parent
Self
How can we contact you?
Home Phone
Work #
Cell #
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Email
*
(Emails are kept confidential)
Confirm Email
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Student #1
Student's First Name
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Last Name
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Birth Date
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Additional Info
Student Email
Classroom #
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Grade Level
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1st grade
2nd grade
3rd grade
4th grade
5th grade
Kindergarten
Pre-K
Does Your Child Have Any Special Needs or Disabilities?
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Allergies
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Medications Including Epi - Pen or Inhalers
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Primary Doctor
Child's Preferred Pronouns?
Who is Authorized for Pick Up?
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Who is Authorized for Pick Up?
Who is Authorized for Pick Up?
Not Permitted Access to Child?
Student #2
(Show-Hide Details)
Student's First Name
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Last Name
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Birth Date
*
Additional Info
Student Email
Classroom #
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Grade Level
*
1st grade
2nd grade
3rd grade
4th grade
5th grade
Kindergarten
Pre-K
Does Your Child Have Any Special Needs or Disabilities?
*
Allergies
*
Medications Including Epi - Pen or Inhalers
*
Primary Doctor
Child's Preferred Pronouns?
Who is Authorized for Pick Up?
*
Who is Authorized for Pick Up?
Who is Authorized for Pick Up?
Not Permitted Access to Child?
Student #3
(Show-Hide Details)
Student's First Name
*
Last Name
*
Birth Date
*
Additional Info
Student Email
Classroom #
*
Grade Level
*
1st grade
2nd grade
3rd grade
4th grade
5th grade
Kindergarten
Pre-K
Does Your Child Have Any Special Needs or Disabilities?
*
Allergies
*
Medications Including Epi - Pen or Inhalers
*
Primary Doctor
Child's Preferred Pronouns?
Who is Authorized for Pick Up?
*
Who is Authorized for Pick Up?
Who is Authorized for Pick Up?
Not Permitted Access to Child?
Student #4
(Show-Hide Details)
Student's First Name
*
Last Name
*
Birth Date
*
Additional Info
Student Email
Classroom #
*
Grade Level
*
1st grade
2nd grade
3rd grade
4th grade
5th grade
Kindergarten
Pre-K
Does Your Child Have Any Special Needs or Disabilities?
*
Allergies
*
Medications Including Epi - Pen or Inhalers
*
Primary Doctor
Child's Preferred Pronouns?
Who is Authorized for Pick Up?
*
Who is Authorized for Pick Up?
Who is Authorized for Pick Up?
Not Permitted Access to Child?
Student #5
(Show-Hide Details)
Student's First Name
*
Last Name
*
Birth Date
*
Additional Info
Student Email
Classroom #
*
Grade Level
*
1st grade
2nd grade
3rd grade
4th grade
5th grade
Kindergarten
Pre-K
Does Your Child Have Any Special Needs or Disabilities?
*
Allergies
*
Medications Including Epi - Pen or Inhalers
*
Primary Doctor
Child's Preferred Pronouns?
Who is Authorized for Pick Up?
*
Who is Authorized for Pick Up?
Who is Authorized for Pick Up?
Not Permitted Access to Child?
Add Another Student
Required Policies
(Show-Hide Details)
I Agree to All of the Above
Enter your Full Name
*
June 30, 2025
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