B REMEN C ITY S CHOOLS A FTER S CHOOL P ROGRAM
2024/2025 E NROLLMENT F ORM
This form needs to be filled out if you did not complete the July 2024 online registration
Please use print and fill out completely. Accurate information is necessary so that we may best serve your
child. It is your responsibility to notify us immediately of any changes in employment or residence. Students
must be potty trained to attend ASP.
Student male/female
First Middle Last Called Name Circle
Birthdate Homeroom Teacher Grade
Address
City State Zip Phone Number cell/home
Circle
Parent/Guardian Relationship
Address (If different from student)
Street/City/State/Zip Code
Phone Number cell/home (circle one)
Employer Work Phone
Email Address (To access myprocare.com)
Is this Parent/Guardian an employee of Bremen City Schools? _____ Yes _____ No
● If yes, please indicated which school _____ JES _____ BA _____ BMS _____ BHS
● Will your child be riding the BCS Shuttle Bus in the afternoons ? _____ Yes _____ No
The preferred way to contact (rank preference order) _____ Text ____ Call ____ Email
Parent/Guardian Relationship
Address (If different from student)
Street/City/State/Zip Code
Phone Number cell/home (circle one)
Employer Work Phone
Email Address
Is this Parent/Guardian an employee of Bremen City Schools? _____ Yes _____ No
● If yes, please indicated which school _____ JES _____ BA _____ BMS _____ BHS
● Will your child be riding the BCS Shuttle Bus in the afternoons ? _____ Yes _____ No
The preferred way to contact (rank preference order) _____ Text ____ Call ____ Email
PLEASE CONTINUE TO THE NEXT PAGE
PICK UP INFORMATION
The person/people you entered in Bremen City Schools online registration are also used by the After School
Program staff to identify people who are authorized to pick up a child other than the child’s parent.
Is anyone legally NOT authorized to pick up your child from the After School Program?
(List Name/Relationship)
Brothers or Sisters in the family? (Name/Age)
Emergency Contacts (List Names/Phone/Relationship)
MEDICAL INFORMATION
Any behavioral or special needs the ASP staff needs to be aware of? ______Yes No
If yes, please explain.
__________________________________________________________________________________________
__________________________________________________________________________________________
Any known allergies?
● Does this allergy require an epi-pen? ______ Yes No
● If so, will you be providing ASP with an epi-pen? Yes No
Please list medications given regularly.
Statements can be viewed on myprocare.com. All payments will be made online at bremencs.com or by sending
in cash or a check to my child’s homeroom teacher.
I assume liability for accidents or injuries incurred during the After-School Program. I authorize the
after-school staff to seek immediate medical attention should the need arise.
By signing this form, I understand and agree to abide by all policies, procedures, and payment policies in
the Bremen City Schools ASP Welcome Letter and your child’s school Student/Parent handbook.
Parent/Guardian Signature Date
