2. This form will allow you to enroll or make changes to your autodraft status in Roanoke County's After School for Kids (A.S.K.) program and Ridge Kids after school program at Green Ridge Recreation Center. New enrollments and changes to your account require at least two weeks advance notice. If your account changes without notifying our office, this may result in your child (or children's) dismissal from the program.

   Automatic draft is required for participants in Ridge Kids. For all other programs, automatic draft via credit card is not required, however, enrollment fees are lower for parents utilizing this service. Automatic draft will occur every other week. If you choose to pay by check for the After School for Kids program, please do not fill out this form.
4. Parent(s) Name*
5. Address (Street, City, State, Zip)*
7. Primary Phone*
8. Secondary / Work Phone*
10. Child, or children's names:*
12. After school site location*

    1. Back Creek Elementary (ASK)
    2. Burlington Elementary (ASK)
    3. Cave Spring Elementary (ASK)
    4. Clearbrook Elementary (ASK)
    5. Green Valley Elementary (ASK)
    6. Herman L Horn Elementary (ASK)
    7. Mason's Cove Elementary (ASK)

    1. Mountain View Elementary
    2. Oak Grove Elementary (ASK)
    3. Penn Forest Elementary (ASK)
    4. W.E. Cundiff Elementary (ASK)
    5. Glen Cove Elementary (ASK)
    6. Glenvar Elementary (ASK)
    7. Mt Pleasant Elementary (ASK)
14. Please check method of payment (card may be either credit or debit)*

    1. Visa
    2. MasterCard
    3. Discover
16. Account Number On Card*
17. Name as it appears on card
19. Card expiration date*
20. CSV Code (three-digit number on reverse of card)*

22. By submitting this form, I authorize Roanoke County Parks, Recreation and Tourism's to initiate automatic withdrawal of payments from my account. Payments will occur bi-weekly. In the case of closure of the account, I agree to reimburse the A.S.K. or Ridge Kids programs for the amount of fees owed and update my payment information immediately.*

    1. I Agree
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit Submit and Print

* indicates a required field