FWMSH Little Scholars Program STUDENT INFORMATION FORM

Name *

First Name Last Name

School Name *

Grade

Does your student have a personal or school-issued computer to use for virtual work at the FWMSH Little Scholars Program ? *

Yes No

Does this student receive special services through FWISD?

No Yes

Please list those services here:

Does your student have any Allergies (food or other) *

Yes No

If yes, please be specific:

Will student be bringing an EPI Pen to class? *

Yes No

Any other medications taken on a regular basis? *

Yes No

Please list medications and dosages here:

Would you like to share any other medical needs, or diagnosis? *

Yes No

Please be specific

Is your student carpooling with other student(s)? *

Yes No

Who will your student be carpooling with?

Will student need transportation (details to follow)

No Yes

Does your child identify as (optional)

White Black or African American Asian Native Hawaiian or Pacific Islander Other

What is the primary language spoken at home?

EMERGENCY CONTACTS: Provide two additional emergency contacts to call if the parent(s)/guardian(s) cannot be reached.

First & Last Name* Phone Number* Relationship to Student

First & Last Name* Phone Number* Relationship to Student*

CHILD RELEASE: Children will only be released to a parent(s)/guardian(s) listed on the application, the emergency contacts listed below or to a person designated below after verification of ID. I authorize The Fort Worth Museum of Science and History to release my child to ONLY with the following persons. There will be no exceptions.

Child Release

First & Last Name Phone Number

Relationship to Student

Child Release

First & Last Name Phone Number

Relationship to Student

Child Release

First & Last Name Phone Number

Relationship to Student

MEDICAL AUTHORIZATON In the event I cannot be reached to make arrangements for emergency medical care, I authorize the Fort Worth Museum of Science and History Museum School to take my child to Cook Children’s Medical Center. I authorize the Fort Worth Museum of Science and History to secure any and all necessary emergency medical treatment and transport for my child.

Signature *

Clear

Printed Name *

First & Last Name Date

Children will only be released to a parent(s)/guardian(s) listed on the application, the emergency contacts listed above or to a person designated above after verification of ID. I authorize The Fort Worth Museum of Science and History to release my child to ONLY with the above persons. There will be no exceptions.

Signature *

Clear

Printed Name *

First & Last Name Date