Ivy Preparatory Academy at Kirkwood for Girls 21st century 2017-2018 Afterschool Program
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Scholar #1 Student First and Last name (please list information for one child, sibling information will be inputted on the second page of application)
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Has your scholar previously been enrolled in the 21st Century Program at Ivy Prep?
Grade
Mailing Address
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Homeroom Teacher (type N/A if information is not available)
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Birthdate
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Age
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Lunch Status?
Ethnicity
Required
Students lives with:
Medical Needs/Restrictions: (allergies, medication, medication schedules, dietary restrictions, behavior disorders etc.)
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Check box if legal restrictions apply
Required
Parent/Guardian First & Last Name
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Parent/Guardian Email Address
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Parent/Guardian Primary Contact Number (specify cell,home or work)
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Additional Parent/Guardian First & Last Name
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Relationship to child ( mother, father, grandparent)
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Additional Parent/Guardian Primary Contact Number
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#1 Emergency Contact First & Last Name (By listing this person you are authorizing them to pick up your scholar)
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Relation to child
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#1 Emergency Contact- Primary Phone Number
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#2 Emergency Contact First & Last Name (By listing this person you are authorizing them to pick up your scholar)
Your answer
Relation to child
Your answer
#2 Emergency Contact- Primary Phone Number
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#3 Emergency Contact First & Last Name (By listing this person you are authorizing them to pick up your scholar)
Your answer
Relation to Child
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#3 Emergency Contact- Primary Phone Number
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