PLEASE Check all Boxes that pertain:
[ ] Registration fee - $15.00 one time fee Date:____________2010-2011
[ ] Mornings only - $10.00 per week Adams Middle School
[ ] After-School only-$25.00 per week 10201 North Boulevard Paid Reg. fee:______/______/_____
[ ] Both- AM & PM - $35.00 per week Tampa, Florida 33612 CK # Amount Date
Phone: (813) 975-7665 ext. 248 Paid 1st week: _____/______/______
PLEASE PRINT CK # Amount Date
Hillsborough County Out-Of-School Time (H.O.S.T.) Program
REGISTRATION FORM
Student Name: ___________________________________ Student
I.D.__________________
Address:_____________________________ City:_____________ FL, Zip Code: _________ Home Phone:________________
Street
Date of Birth:_______________________ Sex:_____________ Grade:_________
Special Needs (medical, allergies, prescriptions taken at school): ________________________________________________________________
Who has custody of STUDENT?______________________________ Relationship to the student:_________________
Mother’s Name:__________________________ Cell Number:_______________ Email address:_______________________
Place of Employment:___________________________________ Work Number:_______________________
Father’s Name:___________________________ Cell Number:_______________ Email address:_______________________
Place of Employment:____________________________________ Work Number:______________________
How will your student get home from the P.M. H.O.S.T. Program: WALK/BIKE/PARENT or Authorized Persons:
__________________________________________________________________________________________
List ALL names of authorized persons who will pick up your son/daughter. Any changes MUST be in writing and signed
by legal guardian. A photo I.D. must be available at time of pick-up.
Name______________________________________ Contact Phone Number__________________________
Name______________________________________ Contact Phone Number__________________________
Students who are not picked up after 6:00 p.m. will be assessed $1.00 per minute. Habitual tardiness (3 or more) in picking up student will result in dismissal from H.O.S.T. program. It will be necessary to initiate “Abandoned Child Procedures” for children remaining at Adams after 6:00 p.m.
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