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St.Catherine of Siena After School Kids Registration Form

Please complete the form below. Required fields marked with an asterisk *

If you have any questions, please email [email protected] or [email protected].

Family Name*

Answer required for "Family Name"

1. Student First Name *

Answer required for "1. Student First Name "

Grade*

Answer required for "Grade"

2. Student First

Answer required for "2. Student First "

Grade

Answer required for "Grade"

3. Student First Name

Answer required for "3. Student First Name"

Grade

Answer required for "Grade"

4. Student First Name

Answer required for "4. Student First Name "

Grade

Answer required for "Grade"

Days Plan to Attend *

Please select all that apply

Answer required for "Days Plan to Attend "

Monday

Tuesday

Wednesday

Thursday

Friday

Occasional

Please list any afterschool clubs that students plan to particpate and use program

Answer required for "Please list any afterschool clubs that students plan to particpate and use program"

Parent/Guardian - Contact Information

Parent/Guardian #1

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

City or Town of Residence

Answer required for "City or Town of Residence"

Primary Email for Contact*

Answer required for "Primary Email for Contact"

Primary Contact Phone*

xxx-xxx-xxxx

Number Required

Phone Type

Answer required for "Phone Type"

Cell

Home

Work

Alternate Phone Number

xxx-xxx-xxxx

Number Required

Phone Type

Answer required for "Phone Type"

Cell

Home

Work

Parent/Guardian #2

First Name*

Answer required for "First Name"

Last Name

Answer required for "Last Name"

City or Town of Residence

Answer required for "City or Town of Residence"

Primary Email

Answer required for "Primary Email"

Primary Phone Number

Number Required

Secondary Phone Number

Number Required

The following people are permitted to pick up my child/children.

Primary Emergency Contact Information

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Primary Email*

Answer required for "Primary Email"

Primary Phone*

xxx-xxx-xxxx

Number Required

Alternate Phone

xxx-xxx-xxxx

Number Required

Relation to child/children*

Answer required for "Relation to child/children"

Please explain any helpful information that we should know about for contact or pick-up.

Answer required for "Please explain any helpful information that we should know about for contact or pick-up."

Secondary Emergency Contact Information

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Primary Email *

Answer required for "Primary Email "

Primary Phone*

xxx-xxx-xxxx

Number Required

Alternate Phone

xxx-xxx-xxxx

Number Required

Relation to child/children*

Answer required for "Relation to child/children"

Please explain any helpful information that we should know about for contact or pick-up.

Answer required for "Please explain any helpful information that we should know about for contact or pick-up."

Medical Release Information

Primary Physician*

Answer required for "Primary Physician"

Phone Number*

xxx-xxx-xxxx

Number Required

Please list any allergies and/or special medical conditions:

Answer required for "Please list any allergies and/or special medical conditions:"

Are their any custody issues?

Answer required for "Are their any custody issues?"

Registration Fee*

One Time Registration Fee

Answer required for "Registration Fee"

$40.00

Saint Catherine of Siena School

FAITH • ACADEMICS • COMMUNITY

Please fix the highlighted areas below before submitting.

After School Kids Registration & Payment Form 2024-2025

St.Catherine of Siena After School Kids Registration Form