HomeAcademicsKidSpace AfterschoolApplication Academics APPLICATION Out-of-School Time Program Registration Form Out-of-School Time Program Registration Form Please fill in ALL information. Please complete a separate form for each student. If you would prefer to fill out and submit physical forms, please download the Student OST Code of Conduct Agreement and the Registration Form and bring them with your child to any of the KidSpace locations. Student Information Start Date: * KidSpace Elementary * Sandstone Elementary Sunset Elementary Hurricane Elementary Free or Reduced Lunch * Free Reduced Pay for Lunch We anticipate students will be attending the program daily. Please specify any day(s) your student will regularly not be attending program due to other engagements (i.e.: sports/recreational activities, scouts, student council, etc). Monday Tuesday Wednesday Thursday Friday OtherOther Student Last Name * Student First Name * Grade * Gender M F Ethnicity (information used for data reporting only) Hispanic Caucasian African American Asian American Indian/Alaskan Native Pacific Islander OtherOther Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Student Date of Birth * Parent/Legal Guardian Contact Information 1st Guardian First Name * 1st Guardian Last Name * 1st Guardian Email * Home Phone Number Cell Phone Number Work Phone Number Authorized Alternative/Emergency Contact(s) for Program and Student Pick-up (PHOTO ID REQUIRED TO PICK UP STUDENT) First Name * Last Name * Relationship to Student * Phone Number * plus1 Add minus1 Remove Departure Options * Pick-Up Only Walk Home Public Transportation Sibling Pick-Up OtherOther Agreements Photo and Media Release As the parent/legal guardian, I give the OST Program permission to use photographs/video taken during the program time for use in different media formats to communicate with the community and other stakeholders. Your initial will act as legal agreement. Health Information and Treatment Consent * Yes No Please check yes if there are any medical conditions that the after-school staff may encounter during the time they spend with us. If your child needs an alternate snack due to medical reasons, please send them with your child. Please describe the medical condition(s) including the appropriate treatment. Visual Code Date * Student OST Code of Conduct Agreement * Student understands that any violation of the Code of Conduct may result in disciplinary action. I hereby grant permission for my student to attend the OST Program. I am aware of the Community & Global Engagement Out of School Time Program Parent Handbook is available online and agree to the regulations and policies set forth therein. I understand that my student must abide by all rules as set forth in the Parent Handbook and as given by the program staff. I agree that if my student fails to follow the rules of the program that they may be asked to withdraw and their spot awarded to another student. I release the OST Program from any and all liability resulting from my student attending the OST Program. I understand that it is my responsibility for the transportation of my student and that late fees may apply if my student is not picked up on time. * Typing your full name will be viewed as your electronic signature. If you are human, leave this field blank. Submit
