Summer and After School Interest form Parent/Guardian Name * First Name Last Name Parent/Guardian contact number * Email * Which Social Emotional Learning Program are you interested in? * 2-5 years of age Summer program 5-12 years of age Summer program How did you hear about our program? * Child's information Child's name * First Name Last Name Child's Date of birth * MM DD YYYY Gender * Male Female Address Address 1 Address 2 City State/Province Zip/Postal Code Country Does the child identify as Black/African American? * Answer yes for Black/African/African American mixed raced identifying children. Yes No Which K-12 school does/will the child attend the 2023-2024 school year? * Alberta Rider Elementary School Art Rutkin Elementary School Bridgeport Elementary School Charles F. Tigard Elementary School Deer Creek Elementary School Durham Elementary School Metzger Elementary School James Templeton Elementary School Tualatin Elementary School Mary Woodward Elementary School Other Other If the your child's school is not on the list, please write it below. What grade will the child enter 2023-2024 school year? * Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade Do you need transportation for your child(ren) to participate in the summer or after school program? * Yes No Will an adult over 18 years of age be available at the bus stop to receive the child daily? * Yes No Primary language spoken in the home * Does the child have an IEP or 504 plan with the school? * Yes No I don't know Do you have any behavior or academic concerns? * Which Programs are you interested in? * Summer School Program Only After School Program Only Summer and After School Program Please complete one form per child. Thank you!
