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Before School / After School
Enrollment Form
Please Choose a Program
Before School 6:30am - 7:30pm
After School 3:15pm - 6:00pm
How many students are you enrolling?
*
1 student
2 students
3 students
4 students
5 students
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Parent/Guardian #1
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Student
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Number
*
Work Number
E-mail
example@example.com
Lives with student
*
Yes
No
Parent/Guardian #2
Parent/Guardian Full Name #2
First Name
Last Name
Relationship to Student
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Number
Work Number
E-mail
example@example.com
Lives with student
Yes
No
Back
Next
Child #1 Details
Student Full Name #1
*
First Name
Last Name
Gender
Male
Female
Not Defined
Grade Level
*
Preschool
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Previous School / Enrollment Details
Has the student ever been in special education?
Yes
No
Has the student ever had a 504 plan?
Yes
No
Medical Conditions
Conditions
Check all that apply
Asthma
Allergy
Heart Condition
Seizures
Diabetes
Other ( please specify below)
Specify Other Medical Condition
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Child #2 Details
Student Full Name #2
*
First Name
Last Name
Gender
Male
Female
Not Defined
Grade Level
*
Preschool
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Previous School / Enrollment Details
Has the student ever been in special education?
Yes
No
Has the student ever had a 504 plan?
Yes
No
Medical Conditions
Conditions
Check all that apply
Asthma
Allergy
Heart Condition
Seizures
Diabetes
Other ( please specify below)
Specify Other Medical Condition
Back
Next
Child #3 Details
Student Full Name #3
*
First Name
Last Name
Gender
Male
Female
Not Defined
Grade Level
*
Preschool
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Previous School / Enrollment Details
Has the student ever been in special education?
Yes
No
Has the student ever had a 504 plan?
Yes
No
Medical Conditions
Conditions
Check all that apply
Asthma
Allergy
Heart Condition
Seizures
Diabetes
Other ( please specify below)
Specify Other Medical Condition
Back
Next
Child #4 Details
Student Full Name #4
*
First Name
Last Name
Gender
Male
Female
Not Defined
Grade Level
*
Preschool
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Previous School / Enrollment Details
Has the student ever been in special education?
Yes
No
Has the student ever had a 504 plan?
Yes
No
Medical Conditions
Conditions
Check all that apply
Asthma
Allergy
Heart Condition
Seizures
Diabetes
Other ( please specify below)
Specify Other Medical Condition
Back
Next
Child #5 Details
Student Full Name #5
*
First Name
Last Name
Gender
Male
Female
Not Defined
Grade Level
*
Preschool
Kinder
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Previous School / Enrollment Details
Has the student ever been in special education?
Yes
No
Has the student ever had a 504 plan?
Yes
No
Medical Conditions
Conditions
Check all that apply
Asthma
Allergy
Heart Condition
Seizures
Diabetes
Other ( please specify below)
Specify Other Medical Condition
Back
Next
Almost done...
Emergency Contact Information
1. Contact Name
*
Relationship to student
Phone Number 1
Phone Number 2
Postal / Zip Code
2. Contact Name
Relationship to student
Phone Number 1
Phone Number 2
Postal / Zip Code
Custody issue regarding the student?
Yes
No
Legal restrictions for any parent?
Back
Next
Last Question...
Special Education Agreement
Choose one of the Following
Option A: My student has never received Special Education Services of any kind or a 504 Plan. (Example of a special education service is Speech, RSP, Occupational Therapy, ETC.)
Option B: My student has an IEP or 504 Plan and I will upload the document and sent to the Enrollment Specialist so a special education team member can contact me and discuss the needs of my student
Please verify that you are human
*
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