Freedom School Oklahoma City, Inc. Summer 2021 Scholar Application
Student Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Prefer Not to Say
Other
Ethnicity
African American
Hispanic/Latino
Asian
Caucasian
Native American/Alaskan
Hawaiian/Pacific Islander
Middle Eastern
Prefer not to answer
Other
Grade: The grade your child will complete in May 2021-We are only accepting applications only for children that are currently in Kindergarten-4th grade. We do not accept children that have not completed all day Kindergarten or who are currently in fifth grade.
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
Has your child previously attended Freedom School?
Yes
No
If yes, what years?
Student has an IEP/Special Education Services?
*
Yes
No
Does your child receive/qualify for Free or Reduced lunch?
*
Yes
No
Contact Information
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Parent(s)/Guardian(s) Information
Parent/Guardian First and Last Name
*
First Name
Last Name
Primary Phone Number
*
-
Area Code
Phone Number
Secondary Phone Number
-
Area Code
Phone Number
What is your annual household income?
*
$0-$24,999
$25,000-$44,999
$45,000-$69,000
$70,000+
How many adults live in the house?
*
1
2
3
4
5
6
7
8
8+
How many children live in the house?
*
1
2
3
4
5
6
7
8
8+
Emergency Contact Information
Emergency Contact 1
*
First Name
Last Name
Primary Phone Number
*
-
Area Code
Phone Number
Secondary Phone Number
-
Area Code
Phone Number
Emergency Contact 2
*
First Name
Last Name
Primary Phone Number
*
-
Area Code
Phone Number
Secondary Phone Number
-
Area Code
Phone Number
Health Information
Family Doctor
First Name
Last Name
Clinic/Hospital Preferred
Phone Number
-
Area Code
Phone Number
Does your child have allergies?
*
List any medications your child is currently taking
*
Has your child had any serious illnesses or operations?
Yes
No
If yes, please describe
Can this child take part in regular physical activities?
*
Yes
No
Do you want to indicate any related information?
Enrollment History
School Your Child Currently Attends
School Name
*
City
State
School District
*
Notes
Please list any educational concerns you may have about your child, for example retention, special education, ADHD, Autism, etc.
Submit
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