2020-2021 EJRP Village Kids Afterschool Registration Paperwork

Basic Information and Contacts

All fields must be fully completed in order to adhere to VT Licensing Standards.

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* 1. Your Child

Child's First Name:

Child's Last Name:

Child's Preferred Name (if different):

Street Address:

Primary phone number:

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* 2. Child's Birth Date

Birth Date

Date

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* 3. Child's Grade (in 20-21 school year)

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* 4. Child's Afterschool Site

Maple Street Park (Summit and Hiawatha Kindergarten)

Hiawatha (1st-3rd)

Summit (1st-3rd)

Fleming (4th-5th)

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* 5. Village Kids/School Start Date (August 26, 2020)

Date / Time

Date

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* 6. Days Attending (Please check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

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* 7. Primary Parent/Guardian:

Name

Address

Home Phone

Cell Phone

Work Phone

Employer

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* 8. Secondary Parent/Guardian (if this does not apply to your family, please enter N/A in all fields)

Name

Address

Home Phone

Cell Phone

Work Phone

Employer

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* 9. Emergency Contact #1 - OTHER THAN parent/guardian

Name

Relationship to child

Address

Cell Phone

Additional phone

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* 10. Emergency Contact #2 - OTHER THAN parent/guardian

Name

Relationship to child

Address

Cell Phone

Additional phone

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* 11. Emergency Care Information

Physician Name and/or Practice Name

Phone Number

Dentist Name and/or Practice Name

Phone Number