Greater Hilltop Area Shalom Zone Registration Form for Summer HYPE
INSTRUCTIONS: Please complete one form for each child enrolled in Summer HYPE. If requested information is non-applicable, mark N/A. If requested information is unavailable or unknown at this time, mark U/A

If completing this form on paper, please mail it to Greater Hilltop Area Zone, PO Box 44083, Columbus, OH 43204.

Please note that the cost for Summer HYPE $10 per family (zip codes 43204, 43223, 43228), $20 per family non Hilltop residents.

Today's Date *
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Child's Name (Last Name, First Name, Middle Initial) *
Your answer
Parent/ Guardian's Name (Last Name, First Name, Middle Initial) *
Your answer
Parent/ Guardian's Work Phone Number (including area code) *
Your answer
Parent/ Guardian's Home/ Cell Phone Number (including area code) *
Your answer
Does this child currently live with you? *
Required
Child's address (include Street Address, City, State, and Zip Code) *
Your answer
Parent/Guardian's address if different from child (include Street Address, City, State, and Zip Code)
Your answer
Child's Preferred Name or Nickname *
Your answer
Child's Date of Birth: *
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YYYY
What is your child's gender: *
Required
What is your child's primary/native language (language spoken at home) *
Your answer
What is your child's race/ethnicity (check one) *
Required
Does your child have any siblings? *
Required
Child's Academic Information
What is the name and address of the school your child attended during the recent school year? Please include street address, city, state, and zip code. *
Your answer
What grade was your child enrolled in during the most recent school year? *
Required
Does your child participate in any of the following educational programs at school (check all that apply) *
Required
Has a doctor, health professional, teacher, or school official ever told you that your child has a learning disability? *
Required
If your child has a learning disability, please explain.
Your answer
Has your child ever repeated a grade *
Required
Has your child ever attended a Shalom Zone freedom school program before *
Required
If yes, how many summers has your child participated in the freedom school program (NOT counting this summer)
Your answer
Child's Medical Information
Does your child have health insurance? *
Required
If yes, please provide information requested below (Insurance Carrier, Group Number, ID Number): *
Your answer
Please explain any special procedures that should be followed in the event that your child has a medical emergency: *
Your answer
Has a doctor or health professional ever informed you that your child has a medical condition or disability? *
Required
If your child has a medical condition or disability, please describe below:
Your answer
Does your child have any dietary, allergies, or exercise restrictions? *
Required
Please describe any dietary, allergies, or exercise restriction below:
Your answer
Does your child currently need or use medication prescribed by a doctor? *
Required
Please list any medications including dosage here:
Your answer
If there is anything else that you would like to share about your child, please indicate below.
Your answer
Please list other adults authorized to pick up your child. Include first and last name, phone number and relationship to child. *
Your answer
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