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OUSD Bret Harte After school Expanded Learning Enrollment
PARENT PERMISSION AND RELEASE AND STUDENT INFORMATION
OAKLAND UNIFIED SCHOOL DISTRICT
ASES and/or 21st CENTURY ELEMENTARY & MIDDLE SCHOOL AFTER-SCHOOL PROGRAMS
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Email
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Your email
I give my child permission to participate in the 2020-21 __________________ After-School Program.
*
Your answer
Name of School
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Your answer
Student's name
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Your answer
Grade
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Your answer
Birth Date
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MM
/
DD
/
YYYY
Parent or Guardian Name
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Your answer
Home Address (Include City & Zip)
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Your answer
Home Phone
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Your answer
Work Phone
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Your answer
Cell Phone
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Your answer
Does your child have health coverage?
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Yes
No
Name of Medical Insurance
Your answer
Policy/ Insurance #
Your answer
Primary Insured’s Name
Your answer
I authorize After-School Program Staff to furnish and/or obtain emergency medical treatment which may be necessary for my child during the After-School Program.
Your answer
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