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Aftercare Drop-In Form

After School Care Drop-In Form

$25.00 per day

Monday - Thursday 3:00 - 6:00pm

Friday 3:00 - 4:30pm
Child's Name
First Name Last Name
I would like to pay for the following: (please describe)
Full Name
First Name Last Name
Phone Number

Area Code Phone Number

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Amount to charge your credit card today:

$
Total

$0.00
Should be Empty:

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