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After-School Program - Returning Student


Student Information

Afterschool Attendance

On what days will your child attend the program?
Tuition Options
  • Individual Days: $25/day
  • Monday-Thursday (4 Days): $90/week
  • Field Trip Friday*: $20/friday
    *Limited spots available
Tuition assistance is available to eligible families. Please contact us for more information if you'd like to learn more.
Will your child need transportation?
Please note that we do not currently pick up from all schools.
Which days will transportation be needed?
If yes, please provide the contact information of the teacher we should communicate with when picking up your child:
Does your child require a carseat/safety seat for transport?
If you select "Yes", you are responsible for providing the carseat or safety seat for your child.

Primary Parent/Guardian Information

Secondary Parent/Guardian Information

Emergency Contacts (other than parents/guardians)

Emergency Contact #1

Emergency Contact #2

Emergency Contact #3


Therapy Services

Medical Information

Are immunizations up to date?
Please upload a copy of the blue immunization form here or bring a copy to Arts 'n Autism.
Upload FIle
Does your child have any allergies?
Does your child have seizures?
Does your child have any food restrictions?
Does your child take any medications that would prevent him/her from participating in all activities of the program?
Please list any medications your child takes on a regular basis or check "None":

Social Information

Does your child currently attend a childcare center, program, or school?

Referred By

How did you hear about Arts 'n Autism?

Personal Information

Type of Family
Household Income

Thank you for submitting! We will be in touch soon for follow-up and next steps.

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