KGBSD Summer School Application
Kindergarten - 6th Grade
Student Name
*
First Name
Last Name
School Last Attended
*
Grade student was enrolled in during 2020-21
*
Gender
*
Male
Female
N/A
Date of Birth
*
-
Month
-
Day
Year
Date
Student has an IEP?
Yes
No
Emergency Information
Parent/Guardian
*
First Name
Last Name
Relationship
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Health Information
Does this child had any serious illnesses that we need to know about?
*
Yes
No
If yes, please describe
Please let us know if this child have any allergies. If none indicate none.
*
List medications if this child is currently taking. If none indicate none.
*
Can this child take part in regular physical activities?
*
Yes
No
Do you want to indicate any related information?
Type of Summer School?
*
In Person
Virtual
Date of Registration
*
-
Month
-
Day
Year
Date
Submit
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