ASP Application

**Enrollment is NOT complete until payment is made.**
After School Program Application

Apply for one or more students below. Transportation will not be provided for ASP. Phone numbers in xxx-xxx-xxxx format. Enter first name then last name.

1. Student Name   Expected Grade Level

2. Student Name   Expected Grade Level

3. Student Name   Expected Grade Level

4. Student Name   Expected Grade Level


Parent 1 Name Parent 2 Name
Custodial Parent/Guardian Information
Relationship to Student Relationship to Student
Home Phone Home Phone
Place of Employment Place of Employment
Business Phone Business Phone
Cell Phone Cell Phone
Email Address Email Address


The following person(s) ARE authorized to pick up my child AND are 18 years of age or older. (ID must be presented. Phone numbers in xxx-xxx-xxxx format.)

NameRelationship to Student1st Phone Number2nd Phone Number

Your child(ren) will only be released to you (parent/guardian) or individual(s) listed above.

Person(s) NOT allowed to pick up student. (Separate multiple names with a comma.)

IN AN EXTREME EMERGENCY: If your child should become seriously ill or injured at school and the parent or physician cannot be reached within a reasonable length of time, may we have your permission to take appropriate action to see that the child gets emergency hospital care?   Yes  No

Parental Acknowledgement - You must read and agree to each statement below to apply for ASP.

I understand that ASP hours are from 2:50PM - 5:30PM only on full school days. The After School Program is not available on early release days.  Yes

I understand that the fee is $50.00 per week per student and an Annual $50 registration fee per family is due at the time of enrollment. The weekly fee of $50.00 per student is due every Friday.   Yes

I understand that families receiving state benefits may qualify for child care assistance.  Please contact the local Social Services Office to coordinate the benefit.   Yes

I understand that slots are filled on a first-come-first-served basis. Enrollment forms will not be processed without the registration and weekly fees.   Yes

I understand that students remaining after 5:35 p.m. will incur a late fee of $10 every 5 minutes.  This fee must be paid before the student can return to the After School Program.   Yes

I understand that the University Academy student code of conduct, as stated in the University Academy handbook applies in ASP. Students experiencing behavior problems may be dropped from the program without advance notice.   Yes

By checking this box, I confirm that I have read and agree to the ASP fees and guidelines.   Yes

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