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ASAP Student Registration Form

Student Information

1. Afterschool Program location *This question is required.

2. Grade Level: *This question is required.

3. Admission Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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4. Child's Name: (First, MI, Last) *This question is required.

5. Birth Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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6. Gender: *This question is required.

7. Special Needs: *This question is required.

8. Street Address *This question is required.

9. City: *This question is required.

10. State: *This question is required.

11. Zip: *This question is required. This question requires a valid number format.

12. Lunch Status: *This question is required.

13. Primary Language:

14. IEP: *This question is required.

15. Behavior Plan: *This question is required.

16. Race/Ethnicity: *This question is required.

Please enter an 'other' value for this selection.

17. Comments on Child's Development:

18. Insurance Status: *This question is required.

Employer Insurance
Healthcare Exchange
Private Insurance
Medicare
Medicaid
Uninsured

19. Medical Issues:

Allergies
Epilepsy
Diabetes
Asthma
Hyperactivity
Attention Deficit Disorder
Eyeglasses/Contacts
Hearing Aid
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.

20. Ability to participate: *This question is required.

21. Please list any allergies, medications, or health problems: *This question is required.

Before admission additional information or accommodations may be requested for children with disabilities and/or special needs who require additional adult support. Once the information is received our team will review to determine if the program can accommodate the needs of the child. Allow a week after documents are submitted for confirmation.