Carter's Crew After School Program Registration

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*
School District Attending*
Name of School
Student Information
Student Name*

First NameMiddle NameLast Name
Gender*
Date of Birth*

MonthDayYear
Date
Last 4 of youth's SSN*
Home Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information (1)
Parent Guardian (1) Name*

First NameMiddle NameLast Name
Home Phone Number

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Last 4 of parent's SSN*
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Parent/Guardian (1) E-mail*
Address same as child?*

YesNo
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

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number

Other Information
Is the child immunized?*

YesNo
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?
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 NameMiddle NameLast Name
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone 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

Clear
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)

YesNo
Should be Empty:

After School Care