SELP Health Form

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SELP Health Form - 2023-24

To register and confirm your spot, you must pay your $180 deposit, complete this form as well as the medical form to be signed by a doctor. If you have a completed medical form on file for EXCEL, you may submit a copy of that.

Once this form is completed, you will receive an invoice from SEED's Finance Director, Ms. Ana Jacobs. Your enrolllment will be complete once we receive all required paperwork and payment as long as slots are still available. We look forward to having your scholar(s) as part of the SEED Extended Learning Program (SELP).

Email *

Today's Date *

YYYY

Scholar's Last Name *

Please type the name of the program participant below.

Scholar's First Name *

Please type the name of the program participant below.

Scholar's Race/Ethnicity (Check all that apply) *

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Asian

Black or African American

Hispanic/Latino

White

Other:

Required

Scholar's Home Address *

Scholar's Grade Level *

Scholar's Birth Date *

YYYY

Scholar's Age

Scholar's Gender Identity *

Female

Male

Non-binary

Declined to state

Other:

Please check any languages your scholar speaks at home. (Check all that apply) *

English

Spanish

French

Other:

Required

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