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    Miller Afterschool Program Student Registration

      2017-2018

    Student Name: _____________________________________________

    Parent/Guardian Name:_____________________________

    Best phone number to reach you: _____________________

    Emergency Contact: _______________________________

    Any allergies/important medical information:____________

    Please list all the ways your student is allowed to transport home:

    ¨     ______ My student may walk/bike home.

    ¨     ______ My student will be riding the bus home each day.

    ¨     ______ Someone will pick up my student each day.

    Please list each person who is allowed to transport your student home. 

    Name: __________________________Phone #: ______________________

    Students will be picked up behind the school.

    Students picked up early from the program must be signed out or have prior permission from parents to do so.

    I have read and agree with the information in this contract:

    Student Signature: _______________________________________________

    Parent/Guardian Signature: _______________________________________

    Hoquiam/ Aberdeen Transportation
    3030 Bay Ave.
    Hoquiam, WA 98550
    Phone: 360-538-8270
       Fax: 360-538-8272