Rosa Parks LEARNS (Kids' Village) After School Program Application 2019-2020
If you are applying past 08/18/19 please email Jessica Baird at jessicabaird@berkeley.net AFTER you have completed your application to finalize registration.

**Please note the current fee scale may change effective the 2019-2020 school year. Also, the fee scale for the before & after school program at Rosa Parks is different from the district fee scale for other LEARNS programs. **

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Email *
Please Select Program/Por Favor Seleccione un Programa *
Enrollment Status/Estado de inscripción *
Please Indicate Days if Part Time/Indique los días si es tiempo parcial
1) Student's Last Name/Apellido del estudiante *
Student's First Name/Primer nombre del estudiante *
Student's Middle Name/Segundo nombre del estudiante *
Date of Birth/fecha de nacimiento *
MM
/
DD
/
YYYY
Gender/ El Género *
Student's Grade/Grado *
Sibling Attending Kids' Village
Please submit the information for the sibling(s) attending Kids' Village as well.
2) Student's Last Name/apellido del estudiante
Student's First Name/primer nombre del estudiante
Student's Middle Name/segundo nombre del estudiante
Date of Birth/fecha de nacimiento
MM
/
DD
/
YYYY
Gender/ El Género
Student's Grade/Grado
Clear selection
3) Student's Last Name/apellido del estudiante
Student's First Name/primer nombre del estudiante
Student's Middle Name/segundo nombre del estudiante
Date of Birth/fecha de nacimiento
MM
/
DD
/
YYYY
Gender/ El Género
Student's Grade/Grado
Clear selection
Student's Home Address/dirección de casa de estudiante *
1) Parent/Guardian     Padre/Tutor Legal *
Primary Phone Number/número de teléfono primario *
Alternative #/# Alterno
Alternative #/# Alterno
Email/correo electrónico
2) Parent/Guardian     Padre/Tutor Legal
Primary Number/número de teléfono primario
Alternative #/# Alterno
Alternative #/# Alterno
Email/correo electrónico
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