PANTHER SUMMER SCHOOL ENROLLMENT FORM
                                        NORTH PLATTE ELEMENTARY SCHOOL  CAMDEN POINT, MO  
                                         Wednesday, June 2nd – Wednesday, June 30th  GRADES K- 8 (Fall Grades)
                                                             COMPLETE THIS FORM BY May 21, 2021
                   For Questions Contact Jolene Hott at mjoteach@aol.com or call 816-506-6131
                                                            COMPLETE ONE FORM PER STUDENT
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Name *
Date of Birth *
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Grade Level for Fall of 2021 School Year *
Parents'/Guardians' Names (First and Last Names) *
Full Address *
Daytime Phone Number *
Cell Number
Work Number
Required emergency contact person other than a parent with phone number in case of emergency if a parent cannot be reached. *
Please indicate what your child will be doing in the morning for transportation. Pick up and drop off times are noted by your choice of location and are APPROXIMATE drop off times . *
Required
Please indicate what your child will be doing in the afternoon for transportation. Pick up and drop off times are noted by your choice of location and are APPROXIMATE drop off times . *
Required
Person(s), non-parental, authorized to pick-up student from Summer School
Please list any health information (If no concerns please enter "None") *
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