Please choose the program site.
*
Discovery Charter (Durham, NC)
Ascend Leadership Academy (Sanford, NC)
Student Name
*
First Name
Last Name
Student Address
*
123 anystreet, city, state, zip
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Student Gender
*
Male
Female
Non-binary
Student Grade
*
5
6
7
8
9
Student Age
*
10
11
12
13
14
Student Birthdate
*
MM
DD
YYYY
Please choose from the list which program you are registering your student for.
*
Early Care Only
Drop-in Care Only**
How many days per week will your child attend?
*
2 days/week
3 days/week
4-5days/week
sporadically (about once per month)
Please tell us any information that would be helpful in caring for your student.
*
List any special conditions that your student has, and share character traits about your student.
Please list any medications that your student takes.
*
If none, write N/A
Authorized Pick-up
*
List all persons authorized to pick up your student. Separate with commas.
Parent 1 Name
*
First Name
Last Name
Parent 1 Address
*
Write "same" in each address box if NOT different from student address.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent 1 Cell Phone number
*
(###)
###
####
Parent 1 Work Phone number
*
(###)
###
####
Parent 2 Name
First Name
Last Name
Parent 2 Address
Write "same" if NOT different from student address.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent 2 Cell Phone number
(###)
###
####
Parent 2 Work Phone number
(###)
###
####
Parent 2 Email
Student resides with
*
Both Parents
Parent 1
Parent 2
Emergency Contact
*
List name, relationship, and phone number. You may list more than one person.
Do you give permission for your student to be photographed/ filmed/ recorded by Quality Care & Enrichment Programs for promotional media purposes?
*
Yes, but please ensure my student is wearing a face mask
Yes, I'm okay with you photographing my student with or without a mask
Yes, but please completely block out my student's face
No, I do not want my student photographed at all
Does your student attend Voyager Academy?
Yes
No