60/40 S.E.T

​REGISTRATION

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This form must be accompanied with the cost of the first week of attendance, and submitted to 60/40SET

                                                    coordinators PRIOR to use of the program.

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SCHOOL___________________________    GRADE______________________________

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CHILD'S NAME____________________________________________________________

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CHILD'S TEACHER_________________________________________________________

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NAME(S) OF SIBLINGS______________________________________________________

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MOTHER'S NAME__________________________________________________________

             ADDRESS__________________________________________________________

        CELLPHONE___________________________________________________________

      WORKPHONE___________________________________________________________

EMERGENCY NUMBER______________________________________________________

PREFERRED EMAIL___________________________________________________________

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FATHER'S NAME____________________________________________________________

           ADDRESS____________________________________________________________

       CELLPHONE____________________________________________________________

      WORKPHONE____________________________________________________________

EMERGENCY NUMBER_______________________________________________________

PREFERRED EMAIL__________________________________________________________

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ALLERGIES/MEDICAL CONDITIONS____________________________________________

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Any Student picked up after 7:00pm will be assesed a $1 per minute beginning at 7:01pm.

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I have read and understand the 60/40 SET rules and guidelines. I understand that failure to follow the rules, or keep my account current will result in the loss of use of the program. I understand that my child may be uninvited from the program for negative behaviors.

 

PARENT SIGNATURE__________________________________     DATE _______________________

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