PS10 PTA Extended Day Online Registration

Welcome to PS10 PTA Extended Day Program!

* denotes required fields

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

New York*

Zip*

Primary Phone

Additional Info

Emergency Contact Info Name and Cell Phone(Not Contact #1 or #2)*

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

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*

Birth Date*

Additional Info

Student Email

Classroom #*

Grade Level*

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?

Not Permitted Access to Child?

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Additional Info

Student Email

Classroom #*

Grade Level*

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?

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*

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?

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*

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?

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*

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?

Not Permitted Access to Child?

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

New York

Zip

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

Required Policies

(Show-Hide Details)