After School Program Registration Page

PLEASE CHECK THE BOX OF THE PROGRAM YOU ARE ENROLLING:
Child's full name:
Gender:
Date of Birth:
Age:
Current school:
Grade:
Home address:
E-mail:

Mother's name:
Phone:
-
Mother's address:
Mother's employer:
Work number:

Father's name:
Father's phone:
-
Father's address:
Father's employer:
Father's work number:

Emergency contact 1:
Emergency contact 1 number:
Emergency contact 2:
Emergency contact 2 number:
Emergency contact 3:
Emergency contact 3 number:

Is there anyone NOT ALLOWED to put up child?:

Does your child need any medication during program time?
Medical condition:
Name of medication:
Dosage:
Allergies, food allergies or other special needs your child has:

Does your child require before school care? If yes, the building opens at 6 a.m. and there is an additional $30 per week cost.

 


After School Program




Be Involved

Ken-Rock Community Center is renowned for its youth recreation sports programs. Over 1,200 boys and girls participate in year round sports and recreational activities. Fun, Sportsmanship and skill development is the focus of these programs along with a stress on character development.


All of Ken-Rock's sports programs depend on volunteers. If you are interested in volunteering contact Athletic Director Ron Adams by email at R.adams@kenrock.org or by phone at (815) 398-8864.

Get in Touch