WLC Summer 2021 Registration Form
Days:  Monday-Wednesday
Time:   5-6:30
Location:  1961 E. Lafayette St.

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Child's First and Last Name:
Date of Birth:
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What grade is your child entering in the fall?
Does your child have an IEP (Special Education) or 504 plan?
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What school does your child attend?
Does your child have any food allergies or dietary restrictions?  Are there any foods you do not want us to serve them? Please list.
Who will be picking your child up at 6:00. List names and phone numbers of those that have your permission to pick your child up from the center:
Parent/Guardian Name
Parent/Guardian Phone number
Parent/Guardian Email
Photographs, Videos and Audio Tapes:  I understand and agree that the Walker Literacy Center can use photographs, videos, audio tapes, test scores of my child for the purpose of promoting and finding funding for our program.   The WLC will only use child's first name/nick name.  These may be posted on the WLC website, Twitter, Instagram, Facebook page and/or any promotional materials.  
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Health Information:  Authorization for medical treatment of minor in the event of a medical emergency.  I am the parent/legal guardian of the above child and I authorize, for medical emergency purpose only, a Walker Literacy Center employee/contract employee to transport the above minor child by ambulance and consent to any necessary medical treatment as deemed by a licensed physician.  The WLC will use the information on this form to contact the parent/guardian as soon as possible.  
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Does your child have any allergies or medical conditions that we need to know about?   If yes, please list.  
Behavioral Expectations:  We want every child's experience at the WLC to be positive.  We will work hard to build positive relationships with your child. The WLC may not be a good fit for every child.   If your child is exhibiting behavioral  challenges we reserve the right to dismiss them from the program.  
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