After School Program Intake Form

Student Information

Student Full Name*

Date of Birth*

Grade / Year*

School Name*

Parent / Guardian Information

Parent / Guardian Full Name*

Parent / Guardian Email*

Parent / Guardian Phone*

Emergency Contact

Emergency Contact Name*

Emergency Contact Phone*

Relationship to Student*

Allergies or Medical Conditions

Special Needs or Accommodations

I authorize the program to administer basic first aid if needed*

Parent / Guardian Signature*

Signature field

What is this form?

A thorough intake form for after-school programs to collect student and parent/guardian information, emergency contacts, medical details, and program preferences. Designed to ensure the safety and well-being of every child in your care.

Who is it for?

After-school program coordinators, community centers, schools, tutoring centers, childcare providers, and youth organizations that need to collect comprehensive enrollment information.