School Age Community Care


Registration Request Form

How to register:

1.) Parent/Guardian must complete the request form below (for each child) PRIOR to registration. This request form only needs to be completed once for each child for the duration of care.

2.) After receiving the form, Ashley Vranick, Youth & Family Director will email the primary parent/guardian listed to continue the registration process. At this point, the parent/guardian will request the type of care (full day/half day) and days needed, etc.

3.) After the initial registration, additional weeks may be registered for by emailing Ashley Vranick directly.

Contact Information
Child Name*:
Primary Parent Name*:
Phone Number*:
Secondary Parent Name*:
Secondary Parent Email*:
Secondary Parent Phone Number*:
Child Information
What school is your child enrolled in?*:
What grade is your child entering in the 2020-2021 school year?:
Does your child have any allergies? If yes, please list*:
Does your child have any special needs? If yes, please list*:
Pick Up Information
Primary Pick Up Person's Name*:
Primary Pick Up Person's Phone Number*:
Estimated Time of Drop Off*:
Estimated Time of Pick Up*:
Additional people authorized to pick up your child. (Must provide first name, last name, and phone number):
#1 Additional Pick Up:
#2 Additional Pick Up:
#3 Additional Pick Up:

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