Student Enrollment Date:Name:* First Last Date of Birth:*01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyearAge:*Gender:*MaleFemaleAddress:* Street AddressCityState / Province / RegionPostal / Zip CodePARENT/GUARDIAN INFORMATION:Parent Name:* First Last Spouse Name:* First Last Home Phone:* Area Code - Phone Number Cell Phone:* Area Code - Phone Number E-mail:*Place of EmploymentWork Phone:* Area Code - Phone Number Please Choose:*CaucasianAfrican AmericanAsianHispanicNative AmericanOtherChild lives with?*EMERGENCY CONTACT (other than parent):Contact Name:* First Last Contact Address:* Street AddressCityState / Province / RegionPostal / Zip CodeContact Phone:* Area Code - Phone Number SCHOOL INFORMATION:School Name:*Grade:*School District:*LRSDPCSSD NLRSDPrivateHomeschoolOtherPlease answer important health information give details where necessary.Chronic Health Problems: (Asthma, Diabetes, other; if yes explain) *Medications: (if yes, please list)*Allergies: (if yes please list All Food/Medications)*Personal Physician: (name and phone number)*Physical Disability: (if yes, give details)*Psychological Disability: (if yes give details)*Please read the following statements before signing below:I hereby certify that my application contains no false information and is complete, truthful, and accurate to the best of my ability.I authorize medical treatment for my child in the case of emergency; I authorize ambulance or emergency services transportation to doctor or hospital.I give permission for photographs of my child in class, during trips or events to be used for advertisement and marketing campaigns associated with the after school program.Your Electronic Signature*SubmitReset