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OUSD Expanded Learning Enrollment Form_Elementary/Middle English
                               PARENT PERMISSION AND RELEASE AND STUDENT INFORMATION
                                                   OAKLAND UNIFIED SCHOOL DISTRICT
                ASES and/or 21st CENTURY ELEMENTARY & MIDDLE SCHOOL AFTER-SCHOOL PROGRAMS
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I give my child permission to participate in the 2020-21 __________________ After-School Program. *
Name of School *
Child's Name *
Child's Grade *
Child's Date of Birth *
MM
/
DD
/
YYYY
Parent/Guardian *
Home Address (Include City & Zip) *
Home Phone *
Work Phone *
Cell Phone *
Does your child have health coverage? *
Name of Medical Insurance
Policy/ Insurance #
Primary Insured’s Name
 I authorize After-School Program Staff to furnish and/or obtain emergency medical treatment which may be necessary for my child during the After-School Program.
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