Student name
*
First Name
Last Name
Student Date of Birth
*
MM
DD
YYYY
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Student School
*
Polk County High School
Polk County Middle School
Polk County Central Elementary School
Saluda Elementary School
Sunny View Elementary School
Homeschool
Grade Level
*
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Does your student receive any of the following services?
My child needs after school for:
*
What days of the week will your child attend
*
Parent/Guardian Name:
*
First Name
Last Name
Email
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Guardian Name #2:
First Name
Last Name
Email
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Does your child have any medical conditions, allergies, and/or disabilities? If yes, fill out the form linked below.
Will your child need transportation?
*
Transportation to center:
*
How often will your child ride the bus?
*
Photo Permission
*
Website Permission
*
Observer Permission:
*
Student Records Permission/Release:
*
Select at least 2.
Student Full Name
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
Parent/Guardian Signature:
*
