Extended School Program Registration Form 2019-2020

Please complete the form below. Required fields marked *

-Please do not enter dashes when entering phone numbers.

Student Information

First Name*

Answer Required

Middle Name

Answer Required

Last Name*

Answer Required

Student Date of Birth *

Answer Required

Please check the box below to indicate which school your child attends. After-school ESP is not offered at Highland or Greene Technology Center. If you child attends Pre-K at one of these locations, they may ride the bus to Hal Henard each day. If your child is in grades K-5 at Highland, they may only attend ESP during full operation days. *

Answer Required

Hal Henard Elementary School

EastView Elementary School

Tusculum View Elementary School

Highland Elementary (Pre-K or full days only)

Greene Technology Center (Pre-K or full days only)

Parent/Guardian Contact Information

Mother's First Name *

Answer Required

Mother's Last Name*

Answer Required

Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal

Answer Required

Mother's email

Answer Required

Mother's Mobile Phone*

Answer Required

Mother's Home Phone

Answer Required

Mother's Work Phone*

Answer Required

Mother's Place of Employment

Answer Required

Parent/Guardian Contact Information

Father's First Name*

Answer Required

Father's Last Name*

Answer Required

Father's email

Answer Required

Father's Mobile Phone*

Answer Required

Father's Home Phone

Answer Required

Father's Work Phone

Answer Required

Father's Place of Employment

Answer Required

Child's Physician or Family Nurse Practitioner Information

Name *

Answer Required

Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Phone*

Answer Required

Please check any allergies that apply *

Answer Required

Peanuts/Tree Nuts

Milk

Seasonal-Pollen, dust, environmental

No Known Allergies

Other:

If other, please list below

Answer Required

Are student immunization records on file with the school?*

Answer Required

Yes

Does your child keep allergy medication and/or an Epi Pen available in the school office or with ESP?*

Answer Required

Yes

Does your child take any medication regularly? *

Answer Required

Yes

If yes, please list medication and times it is taken

Answer Required

Does your child have any health problems or any recurring chronic illness? *

Answer Required

Yes

If yes, please describe

Answer Required

Does your child have any developmental health concerns such as; problem with speech, seeing, hearing, or walking?*

Answer Required

Yes

If yes, please describe

Answer Required

How does your child react when he/she is stressed, angry, or frustrated? *

Answer Required

What is the most effective way you would recommend to discipline your child, excluding physical punishment?*

Answer Required

I authorize emergency medical care for my child. *

Answer Required

Date *

Answer Required

Fee Payment Agreement Information-please check ONLY the days your child will need to attend ESP each week. *

Answer Required

Monday

Tuesday

Wednesday

Thursday

Friday

Everyday

Emergency Contact-Authorized Pick-Up

Please list someone to contact, besides parents, in case of an emergency.

First Name

Answer Required

Last Name

Answer Required

Mobile Phone

Answer Required

Home Phone

Answer Required

Work Phone

Answer Required

Please list name, relationship, and phone number for anyone you wish to have permission to pick-up your child. *

Answer Required

Please sign *

Answer Required

Date *

Answer Required

Please fix the highlighted areas below before submitting.

Extended School Program Registration Form 2019-2020