After School 1-Day Pass Enrollment Details

Family Room After School Registration Form_DAY PASS_Enrollment Details

Primary Adult First Name

Primary Adult Last Name

Secondary Guardian First Name

Secondary Guardian Last Name

Primary Guardian Contact Email

Secondary Guardian Contact Email

Primary Guardian Contact Phone Number

Secondary Guardian Contact Phone Number

Additional Approved Adult Pickups

Child 1 First and Last Name

Child 1 Date of Birth (for accurate age)

Child 1’s Teacher Last Name – Grade – Classroom

Child 1 Health, Medical, Diet

Child 2 First and Last Name

Child 2’s Teacher Last Name – Grade – Classroom

Child 2 Health, Medical, Diet

Child 3 First and Last Name

Child 3’s Teacher Last Name – Grade – Classroom

Child 3 Date of Birth (for accurate age)

Child 3 Health, Medical, Diet

Planned Pick Up Time

Anything else we should know to support your family?

I have read and agree to the Terms and Conditions and Privacy Policies.

I agree to Family Room Chicago LLC picking up my child(ren) from school and bringing them to their business locations for after school programming. I agree to Family Room Chicago LLC and staff coordinating pickup and care with the school for immediate / urgent needs with the school. **I agree to notify Family Room Chicago and the school if my child(ren) will be absent from after school via email at AfterSchool@FamilyRoomChicago.com.