Noto

Academic After School

Program Details

What Your Student Will Get

Payment

Weekly, Bi-Weekly or Monthly

Student First Name*

Student Last Name*

Student Date of Birth*

Parent/Guardian First Name*

Parent/Guardian Last Name*

Parent/Guardian Email*

Parent Phone Number*

Home Address

Name of School Currently Attending*

School Address

Current Grade Level*

Payment Option*

Allergies

Emergency Contact Name*

Emergency Contact Phone Numberne text*

Name of People that CAN NOT pick up student from after care.

We take pictures for marketing purposes. Can you child be included in the pictures?*

Insurance Company Name

Policy Number

Primary Insurance Name