Summer School Enrollment
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Email *
Student last name *
Student first name *
Current grade level *
Home address *
City *
Parent/Guardian Name *
Home Phone Number *
Parent Work Phone Number *
Parent Cell Phone Number *
Emergency Contact Name *
Emergency Contact Phone Number *
Gender *
Student Birth Date *
Current Bus Driver *
Will your child ride the school bus for summer school? *
Please describe any health problems or concerns that the school should be aware of. *
List any medications your child is currently taking at school. *
List any allergies your child has. *
List your child's physician and hospital preference. *
In case of accident or serious illness, I request school personnel to contact me, alternate authorized persons, or the named physician. If it is impossible to contact me, authorized persons, or the physician, the school personnel may make emergency arrangements as necessary to care for my child. *
I will allow any pictures taken of my child during participation in Summer Journey to be used for advertising and promotional purposes. *
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