After School Care
All registrations are received and reviewed on a first come, first serve basis. Upon filling all open free spots, all additional submissions will be added to our waiting list. There is no cost for enrollment in this program. This center will be open Monday thru Friday from 3-7pm for youth ages 12-17 in Pulaski County. The center is located at 6807 West 12th Street Suite A, Little Rock AR 72204
After School Care Registration
Grade Attending
*
Please Select
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
School District Attending
*
Please Select
LRSD
NLRSD
PCCSD
Other
Name of School
Student Information
Student Name
*
First Name
Middle Name
Last Name
Gender
*
Please Select
Male
Female
N/A
Date of Birth
*
-
Month
-
Day
Year
Date
Last 4 of youth's SSN
*
Home Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Parent/Guardian Information (1)
Parent Guardian (1) Name
*
First Name
Middle Name
Last Name
Home Phone Number
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Last 4 of parent's SSN
*
Cell Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Parent/Guardian (1) E-mail
*
Address same as child?
*
Yes
No
Address if different than the child. If your address is different than the child's please fill out the info below. Otherwise move onto the next section.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
-
Area Code
Phone Number
Back
Next
Parent/Guardian Information (2)
Parent Guardian (2) Name
First Name
Middle Name
Last Name
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Last 4 of SSN
*
Work Phone Number
-
Area Code
Phone Number
Parent/Guardian (2) E-mail
example@example.com
Address same as child?
Yes
No
Address if different than the child. If your address is different than the child's please fill out the info below. Otherwise move onto the next section.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Other Information
Is the child immunized?
*
Yes
No
Does the child have any allergies? If yes, list any food or drug allergies below.
*
Does the child have any medical conditions? If yes list any medical conditions below.
*
Does the child require any medication? If yes, please list these medications.
*
Are you able to pickup and drop off your child/children?
Yes
No
Child Pickup Needed
Parents must pick up child from the center everyday before 8pm.
Please list the people authorized to pick up your child.
Does your child have any siblings? If yes, list their name and age(s) below.
*
Emergency Contact - Other than Parent/Guardian
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Additional Information
All registrations are received and reviewed on a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Parent/Guardian Signature
Are you or someone in the household a victim of crime? The definition of Victims of Crime: a person who has suffered physical, sexual, financial, or emotional harm because of the commission of a crime. Project Victims also include stalking, and or bullying. (Additional services may be available)
Yes
No
Submit
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