Extended Day Program Enrollment Form

Student #1 Last Name

Student #1 First Name

Student #1 Gender Student #1 GenderFemaleMale

Student #1 Grade Student #1 GradePre-K (3)Jr. KKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeEighth Grade

Student #1 Medications or Allergies (Leave Blank if N/A)

Student #2 Last Name (Leave Blank if N/A)

Student #2 First Name

Student #2 Gender Student #2 GenderFemaleMale

Student #2 Grade Student #2 GradePre-K (3)Jr. KKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeEighth Grade

Student #2 Medications or Allergies (Leave Blank if N/A)

Student #3 Last Name (Leave Blank if N/A)

Student #3 First Name (Leave Blank if N/A)

Student #3 Gender Student #3 GenderFemaleMale

Student #3 Grade Student #3 GradePre-K (3)Jr. KKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeEighth Grade

Student #3 Medications or Allergies (Leave Blank if N/A)

Name of Authorized Pickup Person #1

Name of Authorized Pickup Person #2

Parent or Guardian #1 Name

Parent or Guardian #1 Relationship to Student(s)

Parent or Guardian #1 Cell Phone Number

Parent or Guardian #1 Work or Other Phone Number

Parent or Guardian #2 Name

Parent or Guardian #2 Relationship to Student(s)

Parent or Guardian #2 Cell Phone Number

Parent or Guardian #2 Work or Other Phone Number

Emergency Contact #1 Name

Emergency Contact #1 Relationship to Student(s)

Emergency Contact #1 Cell Phone Number

Emergency Contact #1 Work or Other Phone Number

Emergency Contact #2 Name

Emergency Contact #2 Relationship to Student(s)

Emergency Contact #2 Cell Phone Number

Emergency Contact #2 Work or Other Phone Number

Do you give permission for your student(s) to go on area walks with the EDP staff? Do you give permission for your student(s) to go on area walks with the EDP staff?YesNo

Parent or Guardian Signature

Date of Submission