MELLO STUDENT APPLICATION

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MELLO STUDENT APPLICATION

MINERS EXTENDED LEARNING & LEADERSHIP OPPORTUNITIES
After School Program
2021-2022 Student Enrollment Form

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* Indicates required question

Email *

Your email

STUDENT NAME: *

Your answer

GRADE: *

Choose

K

1

2

3

4

5

6

7

8

TEACHER: *

Your answer

MAILING ADDRESS: *

Your answer

PHONE NUMBER: *

Your answer

WILL STUDENT BE RIDING A BUS: *

Yes

No

PHYSICAL ADDRESS:

Your answer

ALLERGIES:

Your answer

PRIMARY PARENT/GUARDIAN: *

Your answer

PHONE NUMBER: *

Your answer

WORK PHONE NUMBER:

Your answer

OTHER PARENT/GUARDIAN:

Your answer

PHONE NUMBER:

Your answer

EMERGENCY CONTACT PERSON & PHONE NUMBER *

Your answer

RELATIONSHIP TO STUDENT: *

Your answer

DEADLINE FOR ENROLLMENT IS AUGUST 20, 2021

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