After School Program
Our Afterschool hours are from 2 pm - 6 pm. Your child will be provided with a snack and a water. We are open from 8 am - 6 pm on teacher workdays and some holiday breaks. Invoices will be sent weekly via the email provided on this form. All policies of KLSC must be adhered to as a participate of the program. We do provide transportation from school to the facility. Pick up locations are Belmont Central and Page Elementary. Non-Member afterschool rate is $25 per day and Member rate is $20 per day. You must complete a form for each child attending the afterschool program. Upon submission of this application you will receive your initial invoice for payment via the email provided. Your child's spot is not guaranteed until initial payment is made in full.
I agree to the terms & conditions
Are you currently a member of KLSC?
Yes
No
Child's First Name
Child's Last Name
Child's Birthday
Child's Gender
Male
Female
Parent's Full Name
Parent's Email
Phone Number
Address
Does the child live at the address provided?
Yes
No
Partially
If no, please provide additional address where the child resides.
What days will your child attend the program?
Monday
Tuesday
Wednesday
Thursday
Friday
Entire Week
Will your child require transportation?
Select an option
Yes
No
What school does your child attend?
Emergency Contact Name
Person's Authorized for Child Pick Up & Phone #
Person's Authorized for Child Pick Up & Phone #
Emergency Contact Phone Number
Who is the child's primary Medical Provider?
Insurance Company
Insurance Policy/Group #?
Does your child have any medical conditions?
Yes
No
If yes, please list them below.
Does your child have any allergies?
Yes
No
If you answered yes, please list any medications your child will be taking during after school.
Do you authorize us to administer the medications listed above?
Yes
No
Share any additional information about your child you feel like we should know.
I want to subscribe to the mailing list.
Your Signature
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