ADMIN CAAT ENROLLMENT

TO BE USED BY UAU ADMIN ONLY

I Would Like To Register for the CAAT Program At:(Required)

Select the school program site.

I Would Like To Register for Early Drop Off At PS 8

PS 8 is the only site offering an early drop off program at 7:30am. You can register for early drop off only, or early drop off can be added in addition to the CAAT program at PS 8.

Number of Students I Am Enrolling:(Required)

You will be automatically billed each month for the program based on number of students enrolled. Automatic payments will occur roughly 30 days from the date you register. Please note registration also includes a credit card convenience fee.

Students Name:(Required)

First Last

Current Grade Child Is In:(Required)

Current Class Child Is In:(Required)

Student Two Name:(Required)

First Last

Current Grade Child Is In:(Required)

Current Class Child Is In:(Required)

Student Three Name:(Required)

First Last

Current Grade Child Is In:(Required)

Current Class Child Is In:(Required)

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone Number(Required)

Parent/Guardian One(Required)

First Last

Parent/Guardian One Email Address:(Required)

Enter Email Confirm Email

Parent/Guardian One Employer(Required)

Type NA if unavailable

Parent/Guardian One Employer Address:(Required)

Type NA in fields if no applicable

Street Address Address Line 2 City State ZIP Code

Parent/Guardian One Cell Phone:(Required)

Parent/Guardian One Work Number(Required)

Parent/Guardian Two Name:

First Last

Parent/Guardian Two Email Address:

Enter Email Confirm Email

Parent/Guardian Two Employer:

Parent/Guardian Two Employer Address:

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Two Cell Phone:

Parent/Guardian Two Work Number

Emergency Contact Information

In case of an emergency and the parent/guardian listed above cannot be reached please list two other individuals as points of contact.

Emergency Contact 1 Name:(Required)

First Last

Emergency Contact Cell Phone Number(Required)

Relationship To Child:(Required)

Emergency Contact 2 Name:(Required)

First Last

Relationship To Child:(Required)

Emergency Contact 2 Cell Phone Number(Required)

Emergency Medical Treatment

It is understood that the final disposition in an emergency case, the judgment of the camp authorities will prevail. The recommendation of the parent as indicated below will be respected as far as possible.

Doctor's Name:(Required)

First Last

Doctor's Phone Number(Required)

Should Any Activity Be Restricted? Please list any/all here along with reason why.(Required)

Including Allergies, Physical Limitations Etc.

Allergies To Food?(Required)

Yes

Convulsions/Seizures?(Required)

Yes

Allergies to Medicine?(Required)

Yes

Corrective Device?(Required)

Glasses, hearing aid, etc

Yes

Diabetes?(Required)

Yes

Asthma?(Required)

Yes

Behavioral/Emotional Issues?(Required)

Yes

Physical Disabilities?(Required)

Yes

Does Your Child have special health care needs that require treatment?(Required)

Yes

Does Your Child take any medication for any condition or illness?(Required)

Yes

If You Answered YES to any of the above questions please provide an explanation below:(Required)

Child's Medical Form(Required)

Please upload your child's physical form by clicking browse files. Form must be from within the last 12 months to be considered valid.

Max. file size: 128 MB.

Signature(Required)

Today's Date(Required)

Total

Payment Option(Required)

Please select how you will be paying your balance noted above.

Voucher Number:(Required)

To Whom Was Payment Given?(Required)

First Last