2020 K - 6 Enrollment Form

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* 1. Date

Date

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* 2. Student Information

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* 4. What is your resident school district?

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* 5. Parent/Guardian Name

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* 6. Parent/Guardian Daytime Phone

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* 7. Emergency Contact

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* 9. Student Birthdate:

Date

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* 10. Pirate Pals will be offered during Summer Journey. Do you plan to sign your child up for Pirate Pals during summer school?

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* 12. Transportation Address

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* 13. Other Transportation

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* 14. Heath Problems or Concerns

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* 15. Is your child currently taking medication at school?

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* 16. Is your child allergic to anything?

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* 17. Will your child need medication during Summer Journey?

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* 18. Physician Name and Phone Number:

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* 19. Hospital Preference:

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* 20. In case of accident or serious illness, I request school personnel to contact me, alternate authorized persons, or the named physician. If it is impossible to contact me, authorized persons, or the physician, the school personnel may make emergency arrangements as necessary to care for my child.

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* 21. I will allow any pictures taken of my child during participation in Summer Journey to be used for advertising and promotional purposes.

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