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Afterschool Specials Enrollment Form

Term:

Child's Name:

Child's Grade:

Child's Teacher/Homeroom:

Home Phone:

Parent:

Cell:

Email:

Work Phone:

Parent:

Cell:

Email:

Work Phone:

Emergency Contact Name:

Emergency Contact Phone:

Emergency Contact Cell:

Alternate Pick-up Person Name:

Alternate Pick-up Person Phone:

Alternate Pick-up Person Cell:

Afterschool Specials Class: (choose more than one)

*** New this year, 50% discount available for any child whose parent agrees to attend all sessions as a chaperone.

Explorers' Club--$90 (25% sibling discount)--grades 2-5--(6 Tuesdays--3/27, 4/17, 4/24, 5/8, 5/15, 5/22)
Eco Kids--$80 (25% sibling discount)--grades 1-5--(1st Tuesday every month--10/4, 11/1, 12/6, 2/7, 3/6, 4/10, 5/1, 6/5)

I agree to attend at least one session of Ecokids this year. I am planning to attend Ecokids on the following date(s):

Oct 4
Nov 1
Dec 6
Feb 7
Mar 6
Apr 10
May 1
June 5

Verification Code:

(The verification code is not case sensitive.)

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