InnerCity Solutions, Inc.

After School Program

Sponsored by InnerCity Solutions, Inc. and the AZAR Foundation

Application for STUDENT ENROLLMENT

(Must be school-age (PK3-12th grade) to apply)

PLEASE PRINT. Complete the entire application. Your application will be deemed
incomplete and may not be considered. Please fill out each section. If a section does not
apply to you/your children, please write N/A. Children are required to have written permission (this application
signed by a parent/legal guardian) in order to participate in the ICS After School Program.
Todays Date

Please provide the following information for each child who will be attending
the After School Program (Monday Thursday | 4:30 6:30)

Name (Last, First, Middle):

Childs Date of
Birth:

Childs
Grade

Childs Date of
Birth:

Childs
Grade

Childs Date of
Birth:

Childs
Grade

Childs Date of
Birth:

Childs
Grade

Childs Date of
Birth:

Childs
Grade

Allergies/Medical Conditions:
School:
Name (Last, First, Middle):
Allergies/Medical Conditions:
School:
Name (Last, First, Middle):
Allergies/Medical Conditions:
School:
Name (Last, First, Middle):
Allergies/Medical Conditions:
School:
Name (Last, First, Middle):
Allergies/Medical Conditions:
School:
Parent/Legal Guardian:

Parent/Legal Guardian:

Home Address:
Home Phone:
In Case of
Emergency Contact:
Relationship to you:

ZIP Code:
Work Phone:

Other Phone:

Phone:

I give my child(ren) permission to participate in the InnerCity Solutions, Inc. After School Program. I understand that, before
my child arrives at the Program and when my child leaves the Program premises (with or without permission from Program
staff), InnerCity Solutions, Grace Tabernacle Missionary Baptist Church, and program staff will not be held liable for any
damages or harm that may ensue. Parent/Legal Guardians are responsible for transportation to and from the Program.

Parent/Legal Guardian Signature

Date