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Citizen Schools And OUSD Expanded Learning Enrollment Form
PARENT PERMISSION AND RELEASE AND STUDENT INFORMATION
CITIZEN SCHOOLS & OAKLAND UNIFIED SCHOOL DISTRICT
ASES and/or 21st CENTURY ELEMENTARY & MIDDLE SCHOOL AFTER-SCHOOL PROGRAMS
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* Indicates required question
Email
*
Your email
I give my child permission to participate in the 2020-21 __________________ After-School Program.
*
Yes
Student's name
*
Your answer
Grade
*
6TH Grade
7TH Grade
8TH Grade
Birth Date
*
MM
/
DD
/
YYYY
Parent or Guardian Name
*
Your answer
Home Address (Include City & Zip)
*
Your answer
Home Phone
*
Your answer
Work Phone
*
Your answer
Cell Phone
*
Your answer
Does your child have health coverage?
*
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.
Yes
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