Emerson Elementary Spring 2021 Program Registration Form
DEAR PARENTS, PLEASE FILL ONE FORM PER STUDENT.
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How will the student attend After School? *
Student Date of Birth
MM
/
DD
/
YYYY
Student First Name, Initial Middle *
Student Last Name *
Student's ID number *
Student's Gender *
Ethnicity *
Student Current Grade Level *
Parent/Guardian (First & Last name) *
Parent/Guardian 1 (Cell number) *
Parent/Guardian 1 (Work Number)
Parent/Guardian1 E-mail Address *
Parent/Guardian 2(First & Last name)
Parent/Guardian 2 (Cell number)
Parent/Guardian 2 (Work Number)
Parent/Guardian 2 E-mail Address
Authorize person for pick up?
Please sign me up for the Parent Workshops via virtual platforms?
Once students return back to school, face to face, how will your child get home?
Clear selection
Does student have any known allergies * *
If you selected yes, what allergies does the student have?
I, hereby, give permission for my student to participate on virtual learning platforms, such as: Zoom and Microsoft Teams during the After School program. * *
Secondary Emergency Contact Information Name, Cell Number and Relationship to student *
I, hereby, give permission for the participant to take part in the Texas ACE activities, which include academic assistance, continuing education, and recreational programs.                                                               I further give my consent to the school district and the Texas ACE program, to share the participant’s student records with each other for purposes of providing educational support and assistance.                                                                                  In addition, I understand that HISD and/or Texas ACE will use participant records to evaluate individual progress and improvement. As well as to evaluate the impact of the program on student achievement and to obtain continued funding for the program. By typing my name below, I certify that I have read and do understand the above information. *
Comments and/or questions
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