Student Information

I am interested in registering for the After Care program. Upon registration, I understand an account will be setup and a registration fee of $50 per student will be billed to my account.

Student's First Name

Student's Last Name

Grade and Teacher

After Care Information

I will be using the After Care program for the following:

Please indicate all days of the week that apply.

	Yes
Monday	Yes
Tuesday	Yes
Wednesday	Yes
Thursday	Yes
Friday	Yes

I will be using the After Care program during the sport's season

Adults and/or coaches authorized to pick up and sign my child out of NDES After Care Program. (We realize you may not know your winter/spring coaches. When that information becomes available or information changes, please update the office.)

	First Name	Last Name
#1	First Name	Last Name
#2	First Name	Last Name
#3	First Name	Last Name
#4	First Name	Last Name

Other Information

The After Care program will use the Emergency Medical Authorization information supplied on the Back-to-School form.

Contact Information

First Name *

Last Name *

Phone Number *

Email Address for billing statements *