The Raven's Nest
(Poe Middle School's After-School Program)
Registration Form
Student name:
Middle school team name:
Grade:
Address:
Home phone number:
Cell/Pager number:
Mother's work phone number:
Father's work phone number:
EMERGENCY INFORMATION
Adult contact:
Relationship:
Emergency phone number:
Cell/Pager:
Other Information
Allergies
Insects Bites
Food
Specify Food Allergies:
Other Allergies:
Medications:
Please check the days your child will be attending the After-School Program:
Monday 3:30-4:30 (late bus)
3:30-6:00 (Parent pick-up)
Tuesday 3:30-6:00 (Parent pick-up)
Wednesday 3:30-4:30 (late bus)
3:30-6:00 (Parent pick-up)
Thursday 3:30-4:30 (late bus)
3:30-6:00 (Parent pick-up)
Friday 3:30-6:00 (Parent pick-up)
