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