Child Enrollment Form (English) - Resurrected Community Development Corp

Child Information

Child's Name*

First Middle Last

Birth Date*

Age

Home Address

Street Address Address Line 2 City State ZIP Code

Child's Level*

Level I (grades K-2)
Level II (grades 3-5)
Level III (grades 6-8)
Level IV (grades 9-12)

Gender Identity*

Preferred Pronouns*

Child’s Race/Ethnicity (check all that apply)*

American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
Black or African-American
Hispanic/Latino
White
Other

Is your child an English Language Learner? (English is not their first language)*

Yes
No

Please list any languages your child speaks at home*

Type of school that your child attended this past school year*

Grade just completed*

Does your child receive or qualify for free/reduced price lunch at school during the academic school year?*

Yes
No

Child's School Name*

Child's School Location*

City State / Province / Region

Has your child ever attended a CDF Freedom Schools® Summer program before?*

Yes
No

If yes, how many years has your child participated in the CDF Freedom Schools summer program?

Does your child have health insurance?*

Yes
No

If yes, what is your child’s health insurance carrier?*

Medicaid
N/A

Has your child ever qualified for an Individual Educational Plan (IEP) or 504 plan?*

Yes, IEP
Yes, 504
No

What are some strategies our team can use to best support your child's learning throughout the summer?

(ex: needs additional reading help, prefers small groups)

Does your child have any allergies or health conditions of which we should be made aware? If yes, what?

T-shirt size

Is there anything else that you would like to share about your child?

Family Information

Name of Adult completing this form*

First Middle Last

Relation to Child(ren)*

Parent
Grandparent
Other relative
Other (non-relative)

Is this individual a legal guardian?*

Yes
No

Gender Identity*

Preferred Pronouns*

She
He
They
Other

Home Phone Number*

Cell Phone Number*

Work Phone Number

Email Address*

Alternate Email Address (if applicable)

How many people live in your household?*

# of children in household ages 6-18*

# of children in household 5 and younger*

Emergency Contact Information

Contact Person's Name*

First Middle Last

Is this person authorized to pick up the child(ren) you enrolled in the program? *

Yes
No

Home Phone Number*

Cell Phone Number*

Work Phone Number

Email Address*

Please list other adults who are authorized to pick up the child(ren) you enrolled in the program.

Name	Relationship	Cell Phone Number

In case of an emergency, I give permission for any of the above individuals to be contacted and my child(ren) may be released to any of them.

Are you committed to attending all 6 parent engagement meetings?

Will your child be present all 6 weeks of the program?

.Do you have transportation to and from the site? 8am drop-off /1pm pick-up?

Are you able to volunteer at least once a week?

What site do you prefer? (Select 1)*

Freedom School will be assigning sites based on your preference and availability.

Consent*

I understand that the organization that is enrolling my child(ren) in the CDF Freedom Schools® program is in partnership with the Children’s Defense Fund to offer this summer program. This personal information will be kept private and confidential and will only be shared with CDF to collect demographic information on children served and to report out this information in aggregate form.

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JLFS - Child Enrollment (English)

Child Information

Family Information

Emergency Contact Information