After School Class Registration

After School Program Sign Up Form

Please fully complete the following information and click the "Submit Form" button at the bottom of this page.

School:  

Class Code:   Class Day: MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Start Date:  JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember   12345678910111213141516171819202122232425262728293031   20122013 

Start Time:     AMPM

Child's Name:  

Child's Birthday:  JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember  12345678910111213141516171819202122232425262728293031   201120102009200820072006200520042003200220012000199919981997   

Child's Grade:  Pre-KK123456Other  

Child's Teacher:   

Health Concerns: 

After class my child will:  Attend Day Care at the SchoolWalk HomeBe Picked Up by:

If being picked up, please provide the name and contact number of the person who will be picking up your child:

Name:   

Contact Number:

__________________________________________________________

Parent's Name: 

Parent's Email Address: 

Daytime Phone: 

Evening Phone: 

Cell Phone: 

Street Address: 

City: 

State:    Zip Code:

__________________________________________________________

Please see the form sent home for specific details regarding your child's after school program. The actual amount charged to your credit card will be the amount indicated on the information form distributed by your school. If you have any questions call (303) 403-0432 prior to submitting this form.

Cost (on form): $

Payment Method: CheckCredit Card

If you are paying by check, please proceed to the "Submit Form" button at the bottom of the page.

Credit Card Type:  VisaMasterCardDiscoverN/A

***Credit Card Number***:   

Name on Card: 

Billing Address (if different than above):

Expiration Date:  JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember   20112012201320142015201620172018

By providing this information you authorize Mad Science of Denver to charge your credit card in the amount indicated above. You give permission for your child to attend the Mad Science class and acknowledge that you have read and understand the cancellation and refund policies for the Mad Science of Denver Enrichment program.