21st Century East Dover S.L.A.M Free School Year Application
This application is for the 21st Century afterschool program at East Dover. This program runs Monday-Thursday from 3:15-5:30. Students will have bus transportation as long as in the East Dover feeder. If you will be picking your child up they must be picked up no later than 5:30.
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Email *
Student Name *
Student Phone Number *
Current Grade *
Date of Birth *
Bus Transportation Needed *
Home Address *
Primary Guardian's Name *
Primary Guardians Contact Number *
Secondary Contact Name *
Secondary Contacts Number *
Does your child have any allergies *
List of Allergies
Medications the student is taking
Name of Physician and Physician's Phone Number *
Name of Dentist and Dentist Phone Number *
Name of Insurance *
Insurance Policy Number *
Group Number *
Medicaid Number *
Medical Conditions to be aware of: *
I consent to allow my child to participate in the after school experiences sponsored by 21st Century - East Dover Elementary School. *
In case of illness or injury, Capital School District will attempt to contact both parents at all numbers available. If the parent is unable to be reached, the emergency contacts will be called in the order they are listed. If no emergency contact is reached, appropriate medical care will be provide, including contact the student's physician and transfer by ambulance if necessary to a medical facility for further care and evaluation. The program will continue to call the parents, guardians or physician until one is reached. *
I have read and understood the Program Emergency Procedure and I agree to it its implementation. If I cannot be reached, I agree to assume responsibility for the cost of emergency care including transportation by ambulance if necessary. I consent to any emergency care, treatment, surgery diagnostic procedure or the administration of anesthesia, which may be carried out based on the medical judgement of the attending physician to ensure my child's health, safety and welfare. *
Parent Guardian Signature & Date *
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