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Grace Freedom Summer 2021'
Enrollment Form: Please complete one application for each child enrolled in the Grace Freedom Summer Program.  Please answer each question completely.
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Email Address *
Scholar's Name *
Scholar's DOB *
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DD
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Scholar's Age *
Scholar's Currant Grade *
Parent/Guardian's Name *
Parent's Address/City/State/Zip *
Home Telephone Number *
Cell Telephone Number *
Work Telephone Number *
Parent Best Contact Number *
Emergency Contact Person/Relationship *
Emergency Contact # *
Your Relationship to Child *
Required
Does this child currently live with you? *
If the child does not live with you, what is the child's residential address?                     *
Child's Demographic Information
Child's Nickname: *
Child's Gender *
Child's Age *
What is your child's primary/native language (language spoken at home)? *
Child's Race/Ethnicity (Check One Only) *
Does you child have any siblings? *
Required
If yes, list their full names:
Will the sibling(s) enroll in 2021 Grace Freedom Summer? *
Does your child receive or qualify for free/reduced price lunch at school during the academic school year? *
Has your child been in foster care at any point in his or her life? *
Child's Academic Information
What type of school does your child attend? *
Required
What is the name and address of the school your child attends during the academic school year? *
What grade is your child enrolled in THIS school year? (2021) *
Required
What is your child's level of reading proficiency? *
Required
Does your child participate in any of the following educational program(s)?
Has a doctor, health professional, teacher, or school official ever informed you that your child has special educational needs? *
Required
If yes, please explain:
Has your child ever repeated a grade? *
Required
If yes, please explain:
What other academic enrichment or extra-curricular activities does your child participate in during summer or academic school year (e.g. organized sports, music or dance lessons, academic tutoring, clubs, etc.) *
Child's Medical Information
Please note:  UNDER NO CIRCUMSTANCES SHOULD ANY MEDICATION BE DROPPED OFF AT FREEDOM SUMMER FOR ANY STAFF MEMBER TO ADMINISTER TO SCHOLARS.
Does your child have health insurance? *
If yes, please provide the information requested: Health Insurance Carrier:  Name of Policy Holder:  Identification Number:  Group Number:
Please explain any special procedures that should be followed in the event that your child has a medical emergency: *
Has a doctor, health professional or school offiical ever informed you that your child has any of the following? *
A developmental delay or physical impairment (Please describe below)
Does your child have any known medical conditions or disabilities that are not listed above?  If so, please describe below.
Does your child have any dietary, allergenic, or exercise restrictions?   If there are no restrictions please state no. If there are restrictions please describe in detail below. *
Does your child currently take daily medication prescribed by a doctor? *
Required
If yes, please explain:
Has your child been to a doctor within the past 12 months? *
Required
Is your child limited or prevented in ay way from participating in moderate to strenuous physical activity? *
Required
If yes, please explain:
During the past 12 months, have you been told by a doctor or other health professional that your child has or had any of the following conditions? *
Required
Other (Please explain)
Has your child been to a dentist within the past 12 months?
Has your child been to an optometrist within the past 12 months? *
Required
If yes, please describe the reason for the hospitalization.
If there is anything else that you would like to share about your child, please indicate here.
Scholar Pick Up:  Persons authorized to pick up your scholar.
Person #1 (Name & best contact number) *
Person #2 (Name & best contact number)
Media Release-Please read and check response *
Captionless Image
Required
Signature of Agreement *
Captionless Image
PLEASE NOTE: Due to the uncertainties as it pertains to the COV-19 pandemic, the Grace Freedom Summer program endeavors to operate under the guidelines of the Center for Disease Control and Prevention’s (CDC) Operational Strategies for protecting K-12.
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