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ROBERTS FAMILY DEVELOPMENT CENTER AFTER SCHOOL PROGRAM ENROLLMENT 2020/2021
STUDENT INFORMATION
* Indicates required question
In what School District?
*
Sacramento City School District
Twin Rivers School District
Robla School District
Other:
What school does your child attend?
*
Your answer
Student First Name:
*
Your answer
Student Last Name:
*
Your answer
DOB:(Month/Date/Year)
*
Your answer
Gender
*
Male
Female
Other:
Grade:
*
Your answer
Child's Race/Ethnicity (select only one):
*
Latino/Hispanic
African American/Black, non-latino
Native American/Alaskan Native
Mixed Heritage
White, non-Latino
Native Hawaiian or Pacific Islander
Asian American
Other:
Has this child been in foster care at any point in their life?
*
NO
YES, in past
YES, currently
Does this child CURRENTLY participate in any of the following educational programs?
*
Bilingual Education
ESL/LEP
Special Education/IEP
504
Gifted and Talented (GATE)
None
Have they EVER participated in Special Education or had an IEP or 504 Plan?
*
Yes
No
Does child have health insurance?
*
YES
NO
If so, with who?
*
Your answer
Does child require any medication during program hours? (If yes, please complete Medical Intake Form at our Main Office)
*
YES
NO
If, YES, what medication?
Your answer
Does your child have any allergies or health conditions that we should be aware of? If YES, please explain:
*
Your answer
Do you have more children to sign up?
*
Yes
No
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