After-School Program (ASP) Registration Form

Student Enrollee Information

Student Name

Date of Birth (dropdown)//

Grade

School

Student Name

Date of Birth (dropdown)//

Grade

School

Student Name

Date of Birth (dropdown)//

Grade

School

Student Name

Date of Birth (dropdown)//

Grade

School

Parent/Guardian Information

Parent/Guardian #1

First

Last

Relationship to Student Enrollee (dropdown)

Address

Address Line 1

City

State

Zip Code

Home or Mobile Phone

Work Phone

Email

Parent/Guardian #2

First

Last

Relationship to Student Enrollee (dropdown)

Address

Address Line 1

City

State

Zip Code

Home or Mobile Phone

Work Phone

Email

Emergency Contacts

Emergency Contact #1 Name

Phone

Relationship

Emergency Contact #2 Name

Phone

Relationship

Medical Information

Physician's Name

Physician's Phone

List Known Allergies and/or Medical Conditions:

Medical Release & Consent Agreement

Today's Date (dropdown)

Digital Signature for Medical Release & Consent *

In case of emergency, I understand that every effort will be made to contact the parents or guardians of my child. If I cannot be reached, I hereby give permission to Jasmine Nyree Campus to contact appropriate emergency medical assistance. A Jasmine Nyree Campus staff member will remain with the child until the parents or another authorized adult arrives. Jasmine Nyree staff may not transport program participants.