Club 158 Online Registration

Registration

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Welcome to online registration for the CLUB158 After School Program. Registration is on a first come, first served basis. If you have any questions, email us at club158@ps158.org, IF YOUR CHILD HAS TAKEN A CLUB 158 CLASS LAST YEAR, PLEASE REGISTER THROUGH THE CUSTOMER PORTAL. CLICK ON THE LINK ABOVE: "ALREADY A CUSTOMER?"

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Referral Information

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Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Health Insurance Carrier

Babysitter name

Babysitter phone

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

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Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Grade Level*

Medical Condition

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor & Phone

Just click on the "search" button below to bring up our current class offerings. Then click on the class you are interested in to enroll your child. Please make sure to only select classes that are open to your child's grade and skill level. If a class is full, you can add your name to a wait list- spaces do open up! All online course registrations will receive an email confirmation.

Enroll in Classes

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Grade Level*

Medical Condition

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor & Phone

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Grade Level*

Medical Condition

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor & Phone

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Grade Level*

Medical Condition

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor & Phone

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

Grade Level*

Medical Condition

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor & Phone

Enroll in Classes

Select Class

Add Another Student

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Comments

Payment Information

Credit Card

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Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

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Student #4 (Show-Hide Details)

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