Digital Summer Learning Program Registration form

Program Registration Form / Forma De Registracion Del Programa

Please complete the information requested below.

Question Title

* 1. Childs First Name/ Nombre

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* 2. Childs Middle Name/ Segundo Nombre

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* 3. Childs Last Name/ Apellido

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* 4. Date of Birth/ Fecha de Nacimiento

Date / Time

Date

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* 5. School / Escuela

Other (please specify)

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* 6. Sex/ Sexo

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* 7. Grade the child will be in the 2020-2021 school year / El grado del proximo ano de su hijo(a).

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* 8. Child's Ethnicity and Race / Origen etnico de el menor y raza
Race (check one or more regardless of race) / Raza
(marque uno o mas que uno sin tomar en cuenta la
raza):

American Indian or Alaskan Native/India americana o nativa de Alaska

Native Hawaiian or Other Pacific Islander/asiática/isleña del Pácifico

Black or African American/Negra o africana americana

Hispanic or Latino/Hispanic o Latino

Asian/Asiático

White/Blanco

Other/Otro

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* 9. CHILD IS LIVING WITH/Hijo(a) vive con:

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* 10. Mother/ Madre contact information

First and Last Name

Company

Day Phone/ Telefono de Dia

Email Address

Eve Phone/ Telefono de Dia

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* 11. Father/ Padre contact information

First and Last Name

Company

Day Phone/ Telefono de Dia

Email Address

Eve Phone/ Telefono de Dia

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* 12. OTHER ADULTS WHO CAN PICK UP MY CHILD, OR MAY BE CONTACTED IN CASE OF EMERGENCY/ OTROS ADULTOS QUE PUEDEN RECOGER A MI NINO.A, OR QUE PUEDEMOS LLAMAR EN CASO DE EMERGENCIA:

Name/ Nombre

Relationship / Relacion

Email Address

Phone Number

Question Title

* 13. OTHER ADULTS WHO CAN PICK UP MY CHILD, OR MAY BE CONTACTED IN CASE OF EMERGENCY/ OTROS ADULTOS QUE PUEDEN RECOGER A MI NINO.A, OR QUE PUEDEMOS LLAMAR EN CASO DE EMERGENCIA:

Name/ Nombre

Relationship / Relacion

Email Address

Phone Number

Question Title

* 14. I Understand that a PHOTO I.D. May be required of any adult attempting to pick up my child. / Identificacion sera requerida de cualquier adulto que recoga a su nino/a

I Understand

Digital Summer Learning Program Registration form

Program Registration Form / Forma De Registracion Del Programa

Question Title

* 1. Childs First Name/ Nombre

Question Title

* 2. Childs Middle Name/ Segundo Nombre

Question Title

* 3. Childs Last Name/ Apellido

Question Title

* 4. Date of Birth/ Fecha de Nacimiento

Question Title

* 5. School / Escuela

Question Title

* 6. Sex/ Sexo

Question Title

* 7. Grade the child will be in the 2020-2021 school year / El grado del proximo ano de su hijo(a).

Question Title

* 8. Child's Ethnicity and Race / Origen etnico de el menor y raza Race (check one or more regardless of race) / Raza(marque uno o mas que uno sin tomar en cuenta laraza):

Question Title

* 9. CHILD IS LIVING WITH/Hijo(a) vive con:

Question Title

* 10. Mother/ Madre contact information

Question Title

* 11. Father/ Padre contact information

Question Title

* 12. OTHER ADULTS WHO CAN PICK UP MY CHILD, OR MAY BE CONTACTED IN CASE OF EMERGENCY/ OTROS ADULTOS QUE PUEDEN RECOGER A MI NINO.A, OR QUE PUEDEMOS LLAMAR EN CASO DE EMERGENCIA:

Question Title

* 13. OTHER ADULTS WHO CAN PICK UP MY CHILD, OR MAY BE CONTACTED IN CASE OF EMERGENCY/ OTROS ADULTOS QUE PUEDEN RECOGER A MI NINO.A, OR QUE PUEDEMOS LLAMAR EN CASO DE EMERGENCIA:

Question Title

* 14. I Understand that a PHOTO I.D. May be required of any adult attempting to pick up my child. / Identificacion sera requerida de cualquier adulto que recoga a su nino/a

* 8. Child's Ethnicity and Race / Origen etnico de el menor y raza
Race (check one or more regardless of race) / Raza
(marque uno o mas que uno sin tomar en cuenta la
raza):