2020-21 ESP Registration Form
Please note: A form must be filled out for each child that will be attending.
Student Last Name *
Student First Name *
Date of Birth *
What does your child liked to be called? *
What school does your child attend? *
What grade will your child be entering for the 2020-21 school year? *
Does your child have siblings who will attend ESP? *
If yes, please list siblings names below:
I give permission for my child to be photographed. *
I authorize emergency medical care in the event of an emergency. *
I have accessed given a copy of the ESP parent manual. This can be found at https://www.hcboe.net/esp *
Guardian 1 Name *
Guardian 1 Address *
Guardian 1 Cell Phone *
Guardian 1 Home Phone *
Guardian 1 Employer
Guardian 1 Work Phone
Guardian 2 Name *
Guardian 2 Address
Guardian 2 Cell Phone
Guardian 2 Home Phone
Guardian 2 Employer
Guardian 2 Work Phone
Who has custody of the child: *
Which guardian should we contact first? *
Please list the names of adults who are authorized to pick up your child: *
Please list the names of any adult that is NOT authorized to pick up your child: *
Does your child have food allergies? *
Please list any allergies below:
Emergency Contact Name #1 (parents/guardians will always be notified first) *
Emergency Contact Phone #1 (parents/guardians will always be notified first) *
Emergency Contact Name #2 (parents/guardians will always be notified first)
Emergency Contact Phone #2 (parents/guardians will always be notified first)
Does your child have any difficulty with speech, vision, hearing or any other motor skills? *
If yes, please enter below:
Are immunizations on file and up to date? *
At which school are these immunizations on file? *
Please list any medical conditions ESP staff should be aware of:
ESP will be using REMIND, School Messenger and email to keep parents informed. Please list a telephone number that you wish to receive text messages about the program.
Parent Email address if applicable
Does either parent/guardian work for the Hamblen County School System? *
If yes, please list name, school and title.
Please choose a payment plan below: Parents may choose to change plans one time during the school year free of charge. If another plan change should be made, a $10 fee will be charged each time a plan is changed. *
Please enter the date below *
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