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Registration Form

All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.

Afterschool Care Registration

Expected Start Date

MM slash DD slash YYYY

School Attending

Grade Attending

Will your child need pick up services from school to the aftercare program?

which subjects does your child need help in ?(Required)

What days of the week are you looking for care?(Required)

Student Information

First Name(Required)

Last Name(Required)

Gender(Required)

Male

Female

Birth Date(Required)

MM slash DD slash YYYY

Home(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Health Care #

Doctors Name

First Name Last Name

Doctors Phone Number

Parent/Guardian Information 1

Full Name(Required)

First Name Last Name

Home(Required)

Phone Number(Required)

Cell

Phone Number

Work

Phone Number

Email

Address - Same As Child(Required)

Yes

No

If your address is different than the childs please fill out the info below. Otherwise move onto the next section.

Parent/Guardian 1 Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Information 2

Name(Required)

First Last

Home(Required)

Phone Number(Required)

Cell

Phone Number

Work

Phone Number

Email

Address - Same As Childs

Yes

No

If your address is different than the childs please fill out the info below. Otherwise move onto the next section.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other Infomation

Is your child immunized?(Required)

Yes

No

Does your child have any allergies?(Required)

Yes

No

If yes please list, including any food or drug allergies.

Does your child have any medical conditions?

Does your child require any medication? If yes, please list these medications.

Do you authorize us to administer the medications listed above?

Yes

No

Please list the people authorized to pick up your child.(please include contact )

Does your child have any siblings?(Required)

If yes, what is their age(s)?

Comments

Are you a resident of Harrison Grande?(Required)

If yes, which Apartment unit?

Emergency Contact - Other than Parent/Guardian

Name

First Name Last Name

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home(Required)

Phone Number(Required)

Cell

Phone Number

Work

Phone Number

All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.

Signature

CAPTCHA

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Details Info

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Contact Us

300 Sudbury Drive Cary NC 27513

984-356-9693

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Registration Form

Afterschool Care Registration

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation

Emergency Contact - Other than Parent/Guardian

Details Info

Contact Us