Checks should be made payable to “Scarsdale After School Clubs”  Do not staple check to form.

 One Form per Child, One Check per Family

Child’s Name _______________________________ Grade___________

Amount Enclosed $______ Check No. ____ Teacher__________

Parent(s) Name_________________ Address ___________________________

Home Number ____________ Work/Cell _____________Email____________

Emergency Contact Name _____________________ Number______________

Emergency Contact Name _____________________ Number______________

Club Request

      Club Name           Club Code   Day/ Time               Fee

1. ____________      ______       ___________          $_______

2. ____________      ______       ___________          $_______

3. ____________      ______       ___________          $_______

4. ____________      ______       ___________          $_______

                                                          TOTAL       $____________

My child did not get into a club due to a lottery last semester. My first choice is:

Please lottery my children together.  YES        NO

*I hereby release Greenacres After School Clubs, volunteers and instructors of any liability in connection with any damages and/or injuries that the above named child may sustain as a result of his/her participation in any Greenacres After School Clubs

Circle One                                             AGREE                                  DISAGREE