After School / Camp
Registration Form:
Child’s Full Name: ____________________________________________________
Date of Birth: ________________ Date To begin program: _________________
Name of School: _____________________________________________________
Grade: _______________ Teacher Name: ________________________________
PARENT/GUARDIAN:
Name: _____________________________________________________________
Relationship to child: ___________________ PHONE #: _____________________
Address: ___________________________________________________________
City: ____________________________________________ Zip: _______________
Email: _____________________________________________________________
Occupation:___________________ Place of employment: ___________________
PARENT/GUARDIAN:
Name: _____________________________________________________________
Relationship to child: ___________________ PHONE #: _____________________
Address: ___________________________________________________________
City: ____________________________________________ Zip: _______________
Email: _____________________________________________________________
Occupation:___________________ Place of employment: ___________________
EMERGENCY CONTACTS / AUTHORIZED TO RELEASE
IN CASE OF AND EMERGENCY AND GUARDIANS CANT BE REACHED, THE
FALLOWING ADULT SHOULD BE CONTACTED.
REQUIRED TO BE LOCAL; PARENTS MUST LIST A MINIMUM OF TWO INDIVIDUALS
Name: _____________________________ Cell Phone: ______________________
Address: ___________________________________________________________
City: _______________________________ Zip: ____________________________
Relationship to Child: _________________________________________________
Name: _____________________________ Cell Phone: ______________________
Address: ___________________________________________________________
City: _______________________________ Zip: ____________________________
Relationship to Child: _________________________________________________
PERSON NOT AUTHORIZED TO TAKE CHILD FROM THE AFTERSCHOOL PROGRAM:
(Please attach any court paperwork for documentation.)
Full Name: _________________________________________________________
Full Name: _________________________________________________________
MEDICAL INFORMATION:
Name of Physician: __________________________________________________
Address: ___________________________________________________________
City: ________________ Zip: __________ Phone #: ________________________
Does your child have any identified physical, mental, emotional, or medical
condition, which we should be aware of in order to provide better care for your
child? YES / No
If yes, please specify the condition and any necessary modifications :
___________________________________________________________________
___________________________________________________________________
Is there any medication that your child takes regularly? YES / NO
If yes, please list below…
___________________________________________________________________
___________________________________________________________________
Does your child have any food allergies?
___________________________________________________________________
___________________________________________________________________
Does your child have any other allergies?
___________________________________________________________________
___________________________________________________________________
What is the status of your child’s:
Vision: ________________________
Hearing: _______________________
Speech: ________________________
MEDICAL RELEASE:
In case of an EMERGENCY involving the child on this enrollment form, I authorize
the Employees of Tribo MMA to use the information in the medical section for
emergency medical treatment under the fallowing conditions:
1. An emergency or unanticipated condition requiring
actions for preservation of the life or health of my child.
2. Reasonable attempts to contact
Parent/guardian/emergency contacts have failed
Parent/Guardian Signature:
CONFIDANCIAL AND MANDATED REPORTING:
Everyone on our professional and volunteer staff must obey all professional
and legal standards concerning your child and family confidentiality. Tribo
MMA recognizes everyone’s basic human and legal rights. It is our policy that
all staff, caregivers, and volunteers treat individuals with dignity and respect.
Any staff member, caregiver or volunteer who has knowledge of abuse or
neglect of any individual, or has reasonable knowledge of abuse or neglect of
any individual MUST report to school management
I certify that I have read the above statement and fully understand the
confidentiality and mandated reporting section.
Parent/Guardian Signature:
Billing information:
1. The credit Card on this Childs file will be charged every Friday prier of the
week starts. You must notify management one week before if you like to
make changes to your form of payment.
2. We must have a CARD ON FILE AT ALL TIMES, if payments done by cash or
zelle, must be done before Fridays payments get run.
3. Late payments will result in a $10 late fee per day.
4. Please let us know if your child is absent or you have picked them up
earlier, text management or call before dismissal.
5. Failure to inform us that your child is not in school will result in a $15 fee
6. Registration fees are done once a year not refundable.
7. Payments not done on time will result in not having your child on the pick
up list and will not be picked up by us on Monday in school.
FINANCIAL AGREEMENT:
I GIVE TRIBOMMA PERMISSION TO RUN THIS CREDIT CARD:
VISA/MC/DISC/AMEX
CARD#:_____________________________________________
EXP DATE: ______________ SECURITY CODE: ______________
CARD ADDRESS: ______________________________________
ZIP CODE: ___________________________________________
FOR THE TERMS OF:
CARD HOLDER SIGNATURE:
________________________________ Date : ______________
