BSC/ASC Registration Form

Before & After Care Registration 2017-18


Please Select One: Before School   After School   BSC & ASC

Student Name    Date of Birth 

Student Home Address   Grade Level 



Mother Name   Place of Employment 

Mother Home Address (if different from student) 

Cell Phone #   Work Phone #  

Home Phone #  Email Address 


Father Name   Place of Employment 

Father Home Address (if different from student) 

Cell Phone #   Work Phone #   

Home Phone #   Email Address 

Student lives with:  Both Parents  Mother  Father  



Please respond to the following questions.

1A. Is there a visitation or other court order barring either parent from removing the student during the school day or coming into contact with the student? YES  NO  (If yes, please provide a copy of the court order.)

1B. Parents DO NOT have share parental responsibility.  (If checked, provide school with a copy of the court order.)

2. Does the student have any allergies? YES  NO

If yes, please specify allergy: 

3. Does the student take any medications? YES  NO

If YES, please specify: 

4. Does the student have any illnesses, behavior issues, or physical limitations? YES  NO 

If YES, please specify: 


Please provide name(s) of person(s), other than the parent, aurthorized to pick up the student. Person(s) will be required to show photo identification.

1. Full Name   Relationship to Student 

Cell Phone #   Alternate Phone # 

2. Full Name   Relationship to Student 

Cell Phone #   Alternate Phone # 

3. Full Name   Relationship to Student 

Cell Phone #   Alternate Phone # 



My full name (in place of my signature) indicates an agreement to accept policies and procedures as established by Gardens School of Technology Arts Before and After School Care Programs. I verify that the student registration info provided is true and accurate to the best of my knowledge.

Parent/Guardian Name   Date 


Please read and initial where indicated below. 

Payment & Fee Policies  I understand all monthly fees are due by the first of each month and that a $10 late fee will be assessed if my fees are not paid by the fifth of the month or designated date. I understand that late pick-up results in fees due the following school day. Parent Initial  

Withdrawal/Refund Policy  I understand and agree to give two-week notice withdrawal of my child from either BSC or ASC programs, and that no refunds will be provided for monthly fees paid. Parent Initial  

Sign In/Sign Out Policy  I understand for the safety of my child, any person I designate to drop off or pick up is required to sign in and/or sign out with FULL signature. I further understand designated pick up persons must produce a photo ID upon request at sign-out. Parent Initial  

Teacher/Staff Sign Out  I give my permission for my child to be signed out by SOTA teacher/staff in order to help in classrooms, receive extra help, attend special programs, etc. I understand my child will be under the supervision of school staff during the time they are signed out of aftercare. Parent Initial  

Discipline Policy  I understand my child is required to follow all school rules of behavior, conduct, and discipline during BSC & ASC hours and disregard for the above may result in dismissal from BSC/ASC. I will review and discuss with my child any behavior reports that indicate problems needing to be resolved. I will sign and return any reports by the next school day. Parent Initial  

Technology Guidelines & Internet Permission  I understand my child will follow school technology guidelines when using both personal electronics and/or school technology equipment.  I give my permission for my child to use the internet during BSC/ASC hours. Parent Initial  

Afterschool Movies-‘G’ & ‘PG’ Rated Permission  I give permission for my child to watch ‘G’ & ‘PG’ rated movies during afterschool care hours. Parent Initial   

Afterschool Sports/Activities Permission  I give permission for my child to participate in sports and activities during ASC. I release the program and staff from any responsibility due to injury. Parent Initial  



I have read, understood, and will abide by the Before School Care and After School Care rules, policies, and procedures.

Parent/Guardian Name   Date 

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