CHILD INFORMATION
CHILD NAME
SCHOOL ATTENDING
GRADE 20202021
Kindergarten 1
st
2
nd
3
rd
4
th
5
th
6
th
GENDER
Male Female
BIRTH DATE THIS IS THE FIRST YEAR CHILD WILL ATTEND P.A.R.K.
Yes No
2020-2021 P.A.R.K. Registration Form
PLEASE COMPLETE ONE FORM FOR EACH CHILD.
PARENT INFORMATION
PARENT/GUARDIAN NAME
ADDRESS CITY STATE ZIP
DAYTIME PHONE CELL/OTHER PHONE EMAIL
PARENT/GUARDIAN NAME
ADDRESS CITY STATE ZIP
DAYTIME PHONE CELL/OTHER PHONE EMAIL
EMERGENCY CONTACT INFORMATION
EMERGENCY CONTACT 1 RELATIONSHIP
DAYTIME PHONE CELL/OTHER PHONE EMAIL
EMERGENCY CONTACT 2 RELATIONSHIP
DAYTIME PHONE CELL/OTHER PHONE EMAIL
PROGRAM
PLEASE SELECT ONE
Before-school P.A.R.K., Kingston Center, 3226 Kingston Ave. (
$
95/month for grades K-4)
Before-school Intermediate P.A.R.K., Kingston Center, 3226 Kingston Ave. (
$
107/month for grades 5-6)
After-school P.A.R.K., various school sites (
$
187/month for grades K-4)
Both Before- and After-school P.A.R.K. (
$
282/month for grades K-4)
REGISTRATION/DEPOSIT FEE
$
30 non-refundable deposit fee. Covers both before- and after-school.
Method of payment:
Cash
Apply household credit
Head of Household Name:
Check (Make payable to: City of Grove City)
Credit Card: VISA MasterCard Discover
ACCOUNT NUMBER SECURITY CODE EXP. DATE
Thank you for registering for the 2020-2021 P.A.R.K. program!
Please contact a P.A.R.K. program sta member with changes to any contact information on this form.
FOR OFFICE USE ONLY
SUBMISSION
TIME AND DATE
ENROLLED WAITING LIST
