AFTER SCHOOL ACADEMIC PROGRAM 2018-2019 REGISTRATION

CHILD'S LAST Name:
CHILD'S FIRST Name:
CHILD'S MIDDLE Name:
Gender:	*  MALEFEMALE
Date of Birth:
Age:
Nickname:
School Attending:
Grade in Fall:
Mode of transportation to After School Academic Program:	*  KBCC TransportationStudent TransportationOther
Father's Name:
Father's Place of Employment:
Home Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:	*
Father's Email Address:
Mother's Name	*
Place of Employment:	*
Home Address:	*
City:
State:
Zip:	*
Home Phone:
Work Phone:
Cell Phone:	*
Mother's Email Address:
Are you a member of Kingdom Builders Christian Center?	*  No Yes
Has your child previously attended Kingdom After School Academic Program?	*  No Yes
How did you find out about Kingdom After School Academic Program?	*  BrochureRegistration SignFriend/FamilyOther
Allergies:	InsectMedicationsFoodOutdoorOther
Does your child have physical activity or dietary restrictions?	*  No Yes
Physical Activity
Dietary Restriction
Has your child been evaluated or received treatment or counseling by a Psychologist or Physician for anxiety, emotional or behavior issues, including hyperactivity? **Your answer to this question will not affect your child's acceptance into the program.**	*  No Yes
Persons Authorized to Pick-Up After Schoolers: Only the parents, emergency contact and the person listed below will be authorized to pick up afterschoolers each day. The person picking up afterschoolers must provide photo identification upon request. Please note the After School Policy regarding late fees for picking up aftershoolers after 6:00pm. *
Name 1:	*
Relation:	*
Phone Number:
Name 2:	*
Relation:	*
Phone Number:	*
Name 3:
Relation:
Phone Number
Name 4:
Relation:
Phone Number:
Name 5:
Relation:
Phone Number:
Name 6:
Relation:
Phone Number:
Name 7:
Relation:
Phone Number:
Name 8:
Relation:
Phone Number:
Registration Fee:	* $
Your Email Address	*
Total	$