Out of School Time Contact Information Sheet

Out of School Time Contact Information Sheet

Eckerd Connects S.T.R.I.V.E. AfterSchool or Summer Learning Programs
WHAT SCHOOL(S) DOES YOUR CHILD(REN) ATTEND?
PARENT/GUARDIAN NAME:

First NameLast Name
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT PHONE
Please enter a valid phone number.
PARENT EMAIL ADDRESS
example@example.com
CHILDREN YOU WOULD LIKE TO ENROLL

AFTERSCHOOL: MUST be entering Kindergarten. Ages served is 5-13. SUMMER LEARNING: MUST have completed Kindergarten. Ages served is 5-13.
FIRST NAMEFirst NameLAST NAME Last Name AGE:blanks GRADE (K thru 8th): T-Shirt Size (for summer camp only)
FIRST NAMEFirst NameLAST NAME Last Name AGE:blanks GRADE (K thru 8th): T-Shirt Size (for summer camp only)
FIRST NAMEFirst NameLAST NAME Last Name AGE:blanks GRADE (K thru 8th): T-Shirt Size (for summer camp only)
FIRST NAMEFirst NameLAST NAME Last Name AGE:blanks GRADE (K thru 8th): T-Shirt Size (for summer camp only)
If you have questions, please email nlauderdale@eckerd.org or call (614)221-3398 x 118

Thank you!
Should be Empty:

CHILDREN YOU WOULD LIKE TO ENROLL