AHES After School Program

1Student Information

2Parent Information

3Payment

Registration Form

Student's Name*

First Middle Last

Student's Grade*

Select Program*

Total

Parent/Guardian's Name*

First Last

Parent/Guardian's Email*

Parent/Guardian's Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact - Name*

First Last

Relation with Student*

Emergency Contact - Email*

Emergency Contact - Phone*

Total

After School Program Registration*

Kindly do not use American Express for the payment. If used, additional bank charges may be applicable.

Card Details

Cardholder Name

Comments

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