EdExCo Summer 2018 Enrollment Application
Use this form to enroll children in our Summer 2018 Leadership Academy. Space is limited.

Although it may seem long, this application should take only 5-15 minutes to complete.

Dates: Mondays-Fridays, July 9 - 27
Times: 8:30 AM - 2:00 PM
Location: Most Holy Trinity Catholic Church across from 1435 Mallinckrodt Street, St. Louis, MO 63107 in the Hyde Park neighborhood

Questions? Email Elad at Elad@EdExCo.org or call 314-753-9033.
What is your name? *
Your answer
What are the names of the children you are enrolling? For each child, include: Name, age, and school they go to. *
Your answer
Do you represent that the information you are including in this application is true to the best of your knowledge? If yes, please write your name and the date in the answer as representative of your signature. *
Your answer
In enrolling children into our summer program, do you understand that: Your child may participate in academic and physical activities; Your child may get messy; Your child will work with other children; Your child may use the Internet for academic research; Your child may bring home projects made during the program? *
In enrolling children into our summer program, do you understand that: Your child may be walked to and supervised at a park and garden within five city blocks of the summer academy site? *
In enrolling children into our summer program, do you understand that your child will be attended to by Education Exchange Corps staff from 8:30 AM to 2:00 PM Monday-Friday on days when the Summer Academy is in session? *
In enrolling children into our summer program, do you understand that your child is expected to behave well and that Education Exchange Corps staff may remove your child from the program if your child is being disruptive? *
In enrolling children into our summer program, do you accept the risks that come with the activities your child may do during the Summer Academy, and do you release the Education Exchange Corps and its staff from liability for any injuries or damage to property that may result from your child's participation? *
In enrolling children into our summer program, do you understand that there may be days due to weather or emergencies when the program is temporarily cancelled? *
During our summer program, we take pictures and video to share with families, friends, and the outside community. Sometimes, our children produce these photographs and videos. Do you give us permission to use photographs, videos, and other recordings of you and the children you are enrolling that are taken during our summer academy? *
What is your address? Include street number, street, city, state, and zip code. *
Your answer
What is the best phone number to reach you at? *
Your answer
Do you want to receive texts from us? *
What is the best email address for you?
Your answer
Please list at least two emergency contacts. In case of emergency, we will go in the order that you provide. You may include yourself. For each contact, please include: Name, Relation to Child, Phone Number *
Your answer
Please list the names and phone numbers for your children's primary care doctors. For each doctor, please include: Doctor's Name, Doctor's Phone Number, Name of Child Seen by Doctor *
Your answer
Are any of your enrolled children allergic to medication? If so, please list: Child's Name, Medication Allergy *
Your answer
Do any of your enrolled children have other allergies? If so, please list: Child's Name, Allergy *
Your answer
Do any of your enrolled children have any medical conditions? If so, please list: Child's Name, Condition *
Your answer
Are any of your enrolled children on medication? If so, please list: Child's Name, Medication, Instructions for Use *
Your answer
Have any of your enrolled children had any major medical procedures? If so, please list: Child's Name, Procedure *
Your answer
Is there anything else we should know about your enrolled children? *
Your answer
What would you like your enrolled children to get out of their experience with us this summer? *
Your answer
How did you hear about us? *
Your answer
We value providing children and families with engaging and affordable summer programming. To do that, we fundraise and apply for grants. You can help us continue providing programming by answering a few questions. If you'd like to help, please include below: Estimated Household Income for the Enrolled Children; Number of People in Household.
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Education Exchange Corps. Report Abuse