ROBERTS FAMILY DEVELOPMENT CENTER AFTER SCHOOL PROGRAM ENROLLMENT 2020/2021
STUDENT INFORMATION
In what School District? *
What school does your child attend? *
Student First Name: *
Student Last Name: *
DOB:(Month/Date/Year) *
Gender *
Grade: *
Child's Race/Ethnicity (select only one): *
Has this child been in foster care at any point in their life? *
Does this child CURRENTLY participate in any of the following educational programs? *
Have they EVER participated in Special Education or had an IEP or 504 Plan? *
Does child have health insurance? *
If so, with who? *
Does child require any medication during program hours? (If yes, please complete Medical Intake Form at our Main Office) *
If, YES, what medication?
Does your child have any allergies or health conditions that we should be aware of? If YES, please explain: *
Do you have more children to sign up? *
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