21st Century Student Registration 21-22

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Time- Monday-Friday 3:30-6:30PM
Contact us- drandolp@springisd.org

Student Name *

Birthday *

Grade *

Gender *

Female

Male

Prefer not to say

Other:

Race *

Black or African American

Hispanic

Caucasian or White

Asian/ Pacific Islander

Other:

List any medications, allergies, or health problems. *

Is your child allowed to participate in enrichment activities? *

Yes

Maybe

Parent Name *

Parent Phone Number *

Emergency Contact Name *

Emergency Contact Number *

List Any Authorized Pick Ups *

I hereby give consent for my children to be transported and supervised for emergency medical care. In the event I cannot be reached to make arrangements for emergency medical care and give consent for the program to secure any and all necessary emergency medical care for my child. *

Yes

Select transportation method for your child to travel home. Select all that apply. *

Car

Bus

Walk

Other:

Required

I give consent for my child to travel home by the selected method above. *

Yes

I consent for my child to be photographed during the program for promotional purposes. *

Yes

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