Summer EXCEL-Getting Ready for 5K - 2019
The student must be 5 by September 1, 2019 to enroll in this class. This class will cover readiness skills for 5 Year old Kindergarten. The 5K classes will be held at Fox Prairie Elementary School (1601 W. South Street).

Please complete each section and submit.

Email address *
1. Student First Name *
Your answer
2. Student Last Name *
Your answer
3. Student Birthdate *
Month/Date/Year
MM
/
DD
/
YYYY
4. Primary Address *
street, city, state, zip
Your answer
5. Getting Ready for 5K Section Selection *
Student may only register for ONE section because the number of students per class is limited and the learning activities are repeated.
6. Parent/Guardian Name *
Include any suffix for last name (Jr., III)
Your answer
7. Relationship to Student *
Check one box.
Required
8. Parent/Guardian Contact Number *
This number will be used in case of emergency at Summer School.
Your answer
9. Parent/Guardian Email Address *
Your answer
10. Other Adult in Household Name
First and Last Name
Your answer
11. Other Adult in Household Relationship to Student
12. Other Adult in Household Phone Number
Your answer
13. Other Adult in Household Email Address
Your answer
14. Emergency Contact Name *
Another person, besides the people above, who can be contacted in an emergency and is authorized to pick up the student from school.
Your answer
15. Emergency Contact Relationship to Student *
Check one box.
Required
16. Emergency Contact Phone Number *
Your answer
17. Does the student have any health considerations we should be aware of? *
If Yes, please explain health considerations in item 18.
18. List any health concerns, allergies, special information or instruction for the care of this student. Include any hospital, clinic or physician address and telephone information.
Your answer
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