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Saturday Weekend Enrichment Program
Elevated learning for children age 3-8
Emergency Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Specialty
Pick Up Authorization
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Allergy Information
Food Allergies
Known Reactions
Skin Allergies
Known Reactions
Other Allergies
Known Reactions
Daily Routines
Eating: As part of our programming, we will be offering participants a snack.
Are there any foods you DO NOT want us to offer your child?
Is your child on a special diet
Yes
No
If yes, please explain
What does your child eat with? (mark all that apply)
Fork
Spoon
Hands
What does your child use to drink?
Bottle
Sippy Cup
Open Cup
Daily Routines
Toileting
Does your child need assistance in toileting?
Yes
No
What does your child usually wear in the day?
Diapers
Pull Ups
Underwear
Daily Routine
Play
What is your child's favorite toy/object or song?
Does your child enjoy playing with others
Yes
No
Does your child do well playing alone
Yes
No
What activities does your child enjoy?
Daily Routines
Communication
What other languages are spoken at home?
Daily Routines
Health
Does your child have any health problems?
Yes
No
If yes, please explain
Is your child taking any medication regularly?
Yes
No
If yes, will your child need to be given medication during program? Please explain
What else should we know about your child while working with them? (likes, dislikes, etc.)
Submit
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