IAMBK Initial Program Registration Form 2021

IAMBK Community After School Program (CASP) Registration Form 2021-22

Please fill in the form below.
Child's Name *

Prefix First Name Last Name
Child's Birthdate:
Child's Age
Child's Grade in School
Name of Child's School
Child's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent's First, Last Name
Phone Number *

Area Code Phone Number
E-mail *
Preferred Method of Contact:

Cell Phone Home Phone Email Text
Emergency Contact

First Name Last Name
Emergency Phone #

Area Code Phone Number
List all allergies that your child has:
Select Program(s) in which your child would like to enroll:

Individual and Small Group Tutoring Sessions (ages 6 and up) Teen Counseling Sessions and Life Management (ages 12 and up) Creative Dance Music/Keyboarding (ages 9 and up) Parent Cafe (open to ALL parents) Mentoring
Preferred Method of Service Delivery:

On-Site Virtual Both
IAMBK Products
prev next ( X )
Registration Fee (Required) $ 25.00

T-Shirt - YOUTH $ 8.00

T-Shirt ADULT (up to size XL) $ 10.00

Donation $ 5.00

Total $ 0.00
How did you hear about the program?
Should be Empty:

IAMBK Community After School Program (CASP) Registration Form 2021-22