2023 After School*

Child Name*

First Last

Child's Date of Birth*

Select Gender*

Select Grade*

Enter Current School Name*

Parent/Guardian

Full Name Phone Email

Parent2/Guardian2

Full Name Phone Email

Student Address

Street Address City ZIP / Postal Code

Emergency Contacts

Name Phone Relationship

List all individuals authorized to pick up your child (other than the child’s parents and emergency contacts listed above who are automatically authorized to pick up your child). Identification may be requested from listed individuals.

Name Phone Relationship

Emergency Medical Information

Insurance Provider

Policy No Subscriber Name

Doctor Name

Doctor Phone Number

Doctor Address

Street Address City ZIP Code

List all medical and special conditions such as allergies to food, medicine, etc

Any additional information you want to provide us

Hidden

Date you want to start in the program

Date you want to start in the program*

Select the school/location where you wish the child to be picked up from*

Select the After School Program*

After School Program - $495
After School Program (with transportation from school to Grace Church) - $545
4 days After School Program (with transportation from school to Grace Church) - $495
3 days After School Program (with transportation from school to Grace Church) - $425

Kinder Early Release for first 12 days of school

Kinder and TK program - first 2 weeks of early release starting from August 19

Waiver

I hereby instruct ALLSTARS UNITED EDUCATION FOUNDATION ("AUEF") to use the email addresses on this registration for all communications from AUEF to us until we notify AUEF at info@allstarsu.com of an alternate address. If we do not have access to email, AUEF will use the phone numbers on this registration.

I hereby give my consent to have an athletic trainer, teacher, coach, team manager, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the applicant/participant to a medical treatment facility should an individual listed above consider it to be warranted. I recognize the possibility of physical injury associated with event activities, and hereby release, discharge, and otherwise indemnify AUEF, US Club Soccer, AYSO, AAU, their sponsors, the USSF and its affiliated organizations, and the employees and associated personnel of these organizations, against any claim by or on behalf of the applicant/participant registering herein as a result of that applicant/participant participation in Programs selected above.

I acknowledge that I understand that all registration fees paid are non-refundable.

Waiver Acceptance*

I accept the terms of the Waiver above.

* Registration Fee - $75

Total

$0.00

Allstars STEM Afterschool