PS10 PTA Extended Day Online Registration

Registration

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Welcome to PS10 PTA Extended Day Program! Please complete the following registration form.

* 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* (format=mm/dd/yyyy)

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?

After creating your family account, please feel free to register for September Smash 2022

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

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?

After creating your family account, please feel free to register for September Smash 2022

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

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?

After creating your family account, please feel free to register for September Smash 2022

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

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?

After creating your family account, please feel free to register for September Smash 2022

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date* (format=mm/dd/yyyy)

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?

After creating your family account, please feel free to register for September Smash 2022

Enroll in Classes

Select Class

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

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

Payment Information

Credit Card

Required Policies

(Show-Hide Details)