Does your child take any prescribed medications? *
If yes, please list the medications and doses below.
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Does your child have a mental, emotional, health and/or behavioral diagnoses? (e.g. ADHD, diabetes, anxiety, asthma, etc.) *
if yes, please describe below.
Your answer
Rise Up! provides students with transportation after school. However, parent/guardian pickup is also permitted. Please list any contacts who have permission to pick up your student from Rise Up! *
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Emergency Contact Name *
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Emergency Contact Number *
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Emergency Contact Name *
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Emergency Contact Number *
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Emergency Contact Name *
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Emergency Contact Number *
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By placing an electronic signature below, you agree to enroll your student in the Rise Up! after school program. Rise Up! is a voluntary program. Students are not required to attend unless advised by a parent or Richmond Heights Local School District faculty or administration. Please provide the first and last name of a parent/guardian below. *
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