After School Program Enrollment Form

AM and PM School Program Enrollment Form

2025-2026
Please download the Parental Handbook.

Download the Parental Handbook
Parent's Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Phone Number*

Area CodePhone Number
Parent's Email*
Willie Hutch Jones Educational and Sports Program is pleased to offer our AM and PM School Programs for those families that need care for their children beyond the normal school day. Monthly rates offer substantial savings compared to normal daycare area rates. Early Dismissal Days, are also included in the monthly rate.

Please complete and submit one form for all students being enrolled in the AM and PM School Program.
Student's Full Name*

Last NameFirst Name
Grade in Sept. 2025
Gender*
Date of Birth *

MonthDayYear
Date
Demographics (info used for demographic analysis only)*
Primary Language*
Student's Name

First NameLast Name
Grade in Sept. 2025
Gender
Date of Birth

MonthDayYear
Date
Demographics (info used for demographic analysis only)
Primary Language
Student's Name

First NameLast Name
Grade in Sept. 2025
Gender
Date of Birth

MonthDayYear
Date
Demographics (info used for demographic analysis only)
Primary Language
Student's Name

First NameLast Name
Grade in Sept. 2025
Gender
Date of Birth

MonthDayYear
Date
Demographics (info used for demographic analysis only)
Primary Language
Does Any Of Your Children Have An IEP? Please Indicate Which Child*
Does Your Child Have An 504 Plan? Please Indicate Which Child*
Effective date for enrollment*

MonthDayYear
Please indicate the month and day that this agreement is to take effect. For example, if you will be using the After School Program from the first day of school, enter 09-__-2024.
Indicate the day(s) that you anticipate utilizing the AM School Program:*

MondayTuesdayWednesdayThursdayFridayNo AM Program
Indicate the day(s) that you anticipate utilizing the PM School Program:*

MondayTuesdayWednesdayThursdayFridayNo PM Program
Please indicate your child's default dismissal plan:
My child will remain in the PM School Program until being picked up on:*

MondayTuesdayWednesdayThursdayFriday
My child will take the School Bus on:

MondayTuesdayWednesdayThursdayFriday
Please note any known allergies:
Does it require an EpiPen? If Yes, Please specify student
Diagnosed behavioral or emotional issue? *
If YES, please Specify student and condition
Diagnosed chronic Illness *
If YES, please Specify student and condition
Please specify each person, including the name of parents, who has permission to pick up your child from the PM School Program.
Authorized Person 1:*

First NameLast Name
Relationship
Phone Number 1:*

Area CodePhone Number
Authorized Person 2:*

First NameLast Name
Relationship
Phone Number 2:*

Area CodePhone Number
Authorized Person 3:

First NameLast Name
Relationship
Phone Number 3:

Area CodePhone Number
Child Care Subsidy

Registration fee is not covered by DSS, and it is non refundable. http://www.wnychildren.org
REGISTRATION FEE: Please pay this one-time non-refundable registration fee per child.*

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USDProgram Commitment Fee
Signature*

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Payment Methods

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AM and PM School Program Enrollment Form

Child Care Subsidy