After School Program Registration Student InformationStudent's Name(Required) First Middle Last Student's Date of Birth(Required) MM slash DD slash YYYY Student's Gender(Required) Male Female Academic School Year(Required)What year will you need After-School Care? 2024-2025 Student's Grade Level(Required)After-School Care is only available for Wesleyan students enrolled in TK through 5th-grade. TK K 1st 2nd 3rd 4th 5th Who has primary custody of the student?(Required) Both Parents (Mom & Dad) Mom Dad Joint (Shared Custody) Other Program Hours and CostsAfter-School Program Options(Required)PLEASE NOTE: Our 1-HOur Care, 2:30 – 3:30 pm is FULL for the 2024-2025 school year. The program you select below is for the entire school year. Changes can only be made quarterly and must be approved by Wesleyan’s After-School Care Coordinator. Please contact afterschool@wcatrojans.org. Weekly 3-Hour Care | 2:30-5:30 PM | $90 p/week Daily As Needed Care | 2:30-5:30 PM | $30 p/day Late Pick-Up Acknowledgment(Required)The latest pick-up time available is 5:30 pm. Students picked up past 5:35 pm will receive a late charge of $1.00 per minute. I acknowledge the late pick-up fee. Sibling InformationDoes the student have any siblings enrolled at Wesleyan Christian Academy?(Required) Yes No If yes, please list sibling names and grade levels:Parent InformationParent 1 Name(Required) First Last Parent 1 Email(Required) Parent 1 Cell Phone(Required)Parent 1 Work Phone(Required)Parent 2 Name First Last Parent 2 Email Parent 2 Cell PhoneParent 2 Work PhoneStudent's Medical InformationStudent's Medical ConditionsPlease describe any medical conditions the student might have. This information will be kept confidential and is only used to serve your child better.Student's Pediatrician(Required)Doctor’s Name or Practice NamePediatrician's Phone(Required)Include Area CodePediatrician's Address(Required)Address, Street, City, StateEmergency Care Agreement(Required)I agree that Wesleyan Christian Academy’s After-School Care Coordinator or his/her designee may authorize a licensed physician or medical professional to provide emergency care to my child in the event my child’s physician nor I can be contacted immediately. I understand the Emergency Care AgreementStudent Pick-Up PermissionsPlease list any individuals who have your permission to pick up your child from Wesleyan Christian Academy. These individuals will be asked for ID.Pick-Up Person 1 First Last Relationship to the Student Parent Guardian Relative Friend PhoneEmail Pick Up Person 2 First Last Relationship to the Student Parent Guardian Relative Friend PhoneEmail Acknowledgement of UnderstandingAcknowledgement of Understanding(Required)I have read and understand all of the information in Wesleyan’s After-School Program Registration form and I give my permission for my child to participate in the program. All of the information provided is correct and complete. Further, I understand that participating in Wesleyan Christian Academy’s After-School Program is a privilege and requires that my child obey the After-School Care Teachers and the rules and regulations of the program. If my child fails to follow the rules, I understand that he/she may not be able to continue in the program. I agree to the Acknowledgement of UnderstandingParent's Electronic Signature(Required)By typing my name below I recognize and understand that the electronic signature below and any related fields will be treated by Wesleyan Christian Academy like a physical, handwritten signature on a paper form.
