BPE Virtual Summer Registration form

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* 1. Student Name/ Nombre de Estudiante

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* 2. Gender/Sexo

Female

Male

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* 3. Date of Birth/ Fecha De Nacimiento

Date / Time

Date

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* 4. Grade/ Grado

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* 5. Eligible for free lunch? Eligible para almuerzo gratis?

Yes

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* 6. Ethnicity / Etnicidad

Hispanic/ Hispano

Not Hispanic/ No-Hispano

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* 7. Race/ Raza

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 8. Parent or Guardian Name-- Nombre de Padre o Guardian

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* 9. Parent or guardian Information/ Information de Padre o Guardian

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 10. Emergency Contact / Contacto de Emergencia

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 11. Program Selection / Selección de Programa

Arts and Crafts

Fitness

Boxing

People's identity club

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* 12. I grant Brighton Park Neighborhood Council (BPNC) permission to take photographs and/or videos of me and/or my family. I authorize BPNC to publish and use these images electronically in publications, website content, marketing materials, and other organizational materials.

Doy permiso al Consejo Vecinal de Brighton Park (BPNC) para tomar fotografías y / o videos de mí y / o mi familia. Autorizo a BPNC a publicar y usar estas imágenes electrónicamente en publicaciones, contenido del sitio web, materiales de marketing y otros materiales de organización.

Yes

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* 13. I Consent to allow my child to attend the Brighton Park Elementary School Virtual Program From July 6th - August 14th

Yo doy permiso a mi hijo/a de asistir el programa virtual de la escuela Brighton Park Elementary

(Parents/Guardian Type your name....Padre/Guardian escriba su nombre en texto)

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* 14. Registered by / Registrado por

I am the parent or Guardian / Yo soy el padre/Guardian

BPNC employee via phone (Include name in text box)

BPE Virtual Summer Registration form

Question Title

* 1. Student Name/ Nombre de Estudiante

Question Title

* 2. Gender/Sexo

Question Title

* 3. Date of Birth/ Fecha De Nacimiento

Question Title

* 4. Grade/ Grado

Question Title

* 5. Eligible for free lunch? Eligible para almuerzo gratis?

Question Title

* 6. Ethnicity / Etnicidad

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* 7. Race/ Raza

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* 8. Parent or Guardian Name-- Nombre de Padre o Guardian

Question Title

* 9. Parent or guardian Information/ Information de Padre o Guardian

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* 10. Emergency Contact / Contacto de Emergencia

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* 11. Program Selection / Selección de Programa

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* 13. I Consent to allow my child to attend the Brighton Park Elementary School Virtual Program From July 6th - August 14thYo doy permiso a mi hijo/a de asistir el programa virtual de la escuela Brighton Park Elementary (Parents/Guardian Type your name....Padre/Guardian escriba su nombre en texto)

Question Title

* 14. Registered by / Registrado por