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Einstein's Playground CDF Freedom School Child Enrollment Form
Complete an enrollment form for each child. Each enrolled child will be entered into the lottery that will take place in March (all parents will be invited).
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* Indicates required question
Email
*
Your email
Child's Last Name
*
Your answer
Child's First Name
*
Your answer
Child's Birth Date
*
MM
/
DD
/
YYYY
Child's Age
*
Your answer
Home Street Address (City, State, Zip Code)
*
Your answer
Einstein's Playground CDF Freedom School Site
*
Choose
Einstein's Playground (100 Derby Parkway Birmingham, AL 35210)
T-Shirt Size (*these are children sizes)
*
Choose
XS
S
M
L
XL
XXL
Gender Identity
*
Choose
Female
Male
Prefer not to say
Preferred Pronouns:
*
Choose
She
He
They
Other
Child's Race/Ethnicity (check all that apply)
*
Choose
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
Black or African-American
Hispanic/Latino
White
Other
Is your child an English Language Learner? (English is not their first language)
*
Yes
No
Please list any languages your child speaks at home.
*
Your answer
Type of school that your child attended this past year:
*
Choose
Public
Charter
Private
Home
Other
Grade just completed:
*
Choose
Kindergarden
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Does your child receive or qualify for free/reduced price lunch at school during the academic school year?
*
Yes
No
Child's School Name
*
Your answer
County Your Child's School is located in
*
Your answer
Does your child have health insurance?
*
Yes
No
If yes, what is your child's health insurance carrier?
*
Choose
Medicaid
Other
N/A
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