Crusader Quest Summer Program Enrollment
Please complete a separate enrollment form for each student you are enrolling. Form must be filled out by the students parent/guardian.
All student personal information will be used for enrollment purposes only. Please email Kelly Adams with questions at kadams@usd353.com
Student Last Name: *
Student First Name: *
Student Current Grade Level (20-21 school year): *
Current School Student is Attending (20-21 school year): *
Student Primary Address: *
Does student have an IEP: *
Parent/Guardian Name #1: *
Contact Phone Number: (Please list a primary contact number and a secondary contact number if applicable) *
Parent/ Guardian Name #2:
Contact Number: (Please list a primary and secondary contact phone number if applicable)
Emergency Contact: (Please list two alternate and local relatives or friends along with phone numbers who can be contacted in case the parent/guardian cannot be reached in the event of an emergency) *
Student Allergies/Medical Information & Medications: *
Physician or medical facility to be called in an emergency: *
My child will: (check one)(Checking the "walk home" box gives the Crusader Quest program staff permission to release your student from the program at dismissal time) *
Persons authorized to pick-up my student from the program: (Please list other people authorized to pick up your student along with their phone number) Leave blank if this does not apply to your student.
Student T-shirt Size: *
If there is any other important information you feel the program staff need to be aware of please list below:
Crusader Quest Session Time Enrolling Student In:
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Crusader Quest Session Month Enrolling Student In:
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By checking the box below, you verify the information on your student is complete and accurate. I understand that reasonable measures will be taken to safeguard the health and safety of all participants and I will be notified as soon as possible in the event of an emergency. *
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