QUEST After School Enrichment Program, 2025

Child's Name *

First Name

Last Name

Child's Birth Date *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian #2, if applicable

First Name

Last Name

Mobile Phone #1 *

(###)

###

####

Mobile Phone #2

(###)

###

####

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Emergency Contact #1 *

First Name

Last Name

Phone for Emergency Contact #1 *

(###)

###

####

Emergency Contact #2

First Name

Last Name

Phone for Emergency Contact #2

(###)

###

####

Doctor *

First Name

Last Name

Doctor's Phone *

(###)

###

####

May we use your child's anonymous image for communications and social media? *

Yes

No

Who is allowed to pick up your child at the end of their day with us? *

First Name

Last Name

Second person allowed to pick up your child.

First Name

Last Name