ARK Registration 2012

You have reached the right place to sign up for A.R.K.... Afterschool at Riverdale for Kids! This free program, held on Tuesday afternoons, is for students in grades K - 5. It begins at 3:15 (or school dismissal) and ends at 5:00 pm. Please fill out all of the fields requested below. You may contact Kristin Miller, Youth & Family Activities Director at 724-457-0207 ext 13 or BJ Moore, Director of Discipleship and Education at 724-457-0207 x15 with any questions.

Student's Name
Students current grade in School
School Student Attends
Student's Birth Date
Home Address
Home Phone
Mom's Name
Dad's Name
Who Does the child live with?		Mom Dad Both Parents Together Shared Custody Other
If "Other" Please indicate who the child lives with and a contact phone number
Parent's Email
Best Contact Number during ARK hours
Any Allergies/Medical Conditions/or Behavioral Concerns we should know about?
Note: At ARK we make every effort to welcome and accomodate every child. Should a child have special needs for which individual attention is required that exceeds the ability of our volunteer staff, we may ask that a parent or family-provided companion accompany the child to the ARK program.
Please list individuals who have permission to pick this child up when ARK dismisses