Student Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent / Guardian #1 Name *

First Name

Last Name

Phone *

(###)

###

####

Parent / Guardian #2 Name

First Name

Last Name

Phone *

(###)

###

####

I give permission for my child to be photographed at ACTS for use in our publications and on social media. *

YES

NO

I give permission for my child to take short trips with ACTS offsite to local parks, the famers market, the library etc. *

YES

NO

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

I give my permission for ACTS to call for help and if needed transport my child for medical attention/treatment if needed. *

YES

NO

Summer Programs *

My child is planning on participating in Summer Programs at ACTS

YES

NO

School Year 25/26 Programs *

My child is planning on participating in After School Programs at ACTS for 25/26

YES

NO