After School Registration Child Information Child's Name Nickname Child's Birthdate Gender MaleFemale Address City State Zip Code Does your child or either parents speak another language? (Check all that apply below) Child Mom Dad Indicate in the box below which language(s) Does your child have any special needs you would like us to know about? Yes No If yes, please list the special needs below: List any special needs that your child may have, such as allergies, existing illness, previous serious illness, injuries, and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver's should be aware of.
