2019-2020 Urban Discovery Academy Extended Day
Email address *
Student Information
Last Name *
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First Name *
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Date of Birth *
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DD
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YYYY
Grade *
Preferred Contact Number *
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Household Address *
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City *
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Zip Code *
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Mailing Address (If different form home address)
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Sibling Information
Sibling Name (Last)
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Sibling Name (First)
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Sibling Grade
Sibling Name (Last)
Your answer
Sibling Name (First)
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Sibling Grade
Sibling Name (Last)
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Sibling Name (First)
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Sibling Grade
Contact Information (Enrolling Parent/Guardian)
Name *
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Relationship to Student *
Your answer
Lives with student? *
If you do not live with student, please provide address
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Primary Language *
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Home Phone Number *
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Cell Phone Number *
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Email Address *
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Employer *
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Work Phone Number *
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Other Parent/Guardian
Full Name
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Relationship to Student
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Lives with student?
Authorized to pick up student?
If not residing with student, provide address
Your answer
Primary Language
Your answer
Home Phone Number
Your answer
Cell Phone Number
Your answer
Employer
Your answer
Work Phone
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Additional Emergency Contact (Also Authorized for Pick Up)
Name *
Your answer
Phone *
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Email
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Relationship *
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Name *
Your answer
Phone *
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Email
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Relationship *
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Student Health History
List any medical conditions (If none, write "NA") *
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Will your student require medication during after care ? *
If medication is needed complete the Authorization to Administer Medication Form
List any allergies (If none, write "N/A") *
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Media Release
I agree to photos, films, slides, videos, etc., of my child to be be published publicly and/or on social media sites *
Acknowledgement
In signing below, I acknowledge and am in agreement with the After school Attendance policy and the 2019-2020 Urban Discover Academy Parent/Guardian Handbook. *
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Attendance
How many days a week will your student attend? *
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Which day(s) of the week will your student attend? *
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Payment Information
What is your intended method of payment *
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