Saluda Elementary PEAK Application
PEAK After School details and policies can be reviewed at https://sites.google.com/a/polkschools.org/after-school/ They are also posted at each site and available from the PEAK director.
Student Name
Your answer
Date of birth
MM
/
DD
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YYYY
Grade
Address
Your answer
Primary Guardian Name
Your answer
Relationship to student
Your answer
Guardian primary phone/cell phone number
Your answer
Guardian e-mail address
Your answer
Guardian address
Your answer
Preferred method of contact
Secondary Guardian Name
Your answer
Relationship to student
Your answer
phone/cell phone number
Your answer
address
Your answer
Please list any allergies your child has:
Your answer
Please list any illnesses/medical conditions your child has:
Your answer
Please list the names of anyone who has your permission to pick up your child from After School. Students will not be released to anyone who is not listed below without the written/verbal permission of that child’s legal guardian.
Your answer
If neither guardian can be reached in an emergency situation, please provide an alternate contact and phone number:
Your answer
By signing your name below and submitting this form you agree to all PEAK After School policies and Code of Conduct, which can be found under Policies on the PEAK web page. You also agree that PEAK After School staff may seek medical attention for your child in the result of an emergency.
Your answer
You will be notified within 5 business days of submitting this form, if there is a spot available for your child in the PEAK program. You can contact PEAK Director, Linley Foster, with any questions or comments at (828) 894-3051 or lfoster@polkschools.org
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