Register for School Age Services

How did you hear about us?*

Web Search
Friend/Word of Mouth
Flyer/Brochure/Mailer
School District
Yellow Pages
Social Media
Advertisement
Yard Sign or Banner
Other

Location (School)*

Before School

Monday
Tuesday
Wednesday
Thursday
Friday

Please select the days for which you'd like to enroll your children. There is a two day per week minimum.

After School

Monday
Tuesday
Wednesday
Thursday
Friday

Please select the days for which you'd like to enroll your children. There is a two day per week minimum.

Today's Date*

Please enter your desired start date ***NOTE: Start date MUST be 2 full business days from today's date****

MM

DD

YYYY

Your child's start date must be at least two business days after registration date. For registrations submitted after 12:00PM, the following business day will be considered the registration date.

Are you eligible for:*

State Case/Social Worker (if applicable):

Child's Name*

First Last

Gender*

Female
Male

Race

Date of Birth*

MM

DD

YYYY

Parent/Guardian Primary Mailing Address and Contact Information

This information will be automatically entered into the Community Safe interactive system. When there are situations which require immediate attention you will be notified via email, voicemail, or text message. This system will give you updates, closings, delays, and reminders. It is very important that we keep accurate information so that we can reach you in case of an emergency. It is vital that you provide up-to-date contact information. If any of your information changes please contact us at (859) 431-2075 and ask for Diana.

Name*

First Last

Employer*

Work Phone

Cell Phone

Email

Primary Home Address*

Street Address Address Line 2 City State ZIP Code

Primary County*

Primary Home Phone*

Parent/Guardian Secondary Contact Information

This information will be automatically entered into the Community Safe interactive system. When there are situations which require immediate attention you will be notified via email, voicemail, or text message. This system will give you updates, closings, delays, and reminders. It is very important that we keep accurate information so that we can reach you in case of an emergency. It is vital that you provide up-to-date contact information. If any of your information changes please contact us at (859) 431-2075 and ask for Diana.

Name*

First Last

Employer*

Work Phone

Cell Phone

Email

May we give information regarding your child to parent/guardian #2?

Yes
No

Emergency Contact 1 other than parent/guardian listed above*

First Last

Primary Phone*

Secondary Phone

Emergency Contact 1: Permission to Pick Up?*

Yes
No

Emergency Contact 2 other than parent/guardian listed above

First Last

Primary Phone

Secondary Phone

Emergency Contact 2: Permission to Pick Up?

Yes
No

Is there any additional information you'd like to share that would help us better serve your child? For example, any special physical or emotional needs, behavioral issues, health concerns or allergies? If you have any other questions, comments, or issues please use this space for those. Thanks!

Immunization Certificate*

I understand that a current Immunization Certificate must accompany this enrollment and I agree to provide one during my child's first week of attendance.

Name of Physican*

Physician Phone Number*

Preferred Hospital*

Click here to grant Emergency Medical Authorization