TEAMWorks Student Enrollment Form

Student Enrollment form

2021-2022 School Year
Child's Name*

First NameLast Name
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Gender*
Child's Date of Birth
3rd grade4th grade5th grade6th grade
Child's T-Shirt Size*
Parent/ Guardian Information
Parent/ Guardian 1*

First NameLast Name
YesNo
Relationship to the child:*
Cell Phone Number*

Area CodePhone Number
Email*
example@example.com
Parent/ Guardian 2

First NameLast Name
YesNo
Relationship to the child:
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact Information
Emergency Contact #1*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Phone*

Area CodePhone Number
Emergency Contact #2*

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Phone*

Area CodePhone Number
Emergency Contact #3

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone

Area CodePhone Number
Medical
Does your child have a pediatrician or primary care doctor? Please give their name:
Doctor's Phone Number

Area CodePhone Number
Does your child have a dentist? Please give their name:
Dentist's Phone Number

Area CodePhone Number
List any food or environmental allergies your child has: if none write 'none'*
List any special health or medical conditions your child has: if none write 'none'*
Availability- Time Commitment
YesNo
If No, Please explain:
Dismissal Instructions

At the conclusion of TEAMWorks (6:30)PM my child will be picked up by: please list those authorized to pick up your child. We cannot release your child to anyone who is not on this list. (This includes siblings)
Name*

First NameLast Name
Relationship to the child:*
Phone*

Area CodePhone Number
Name

First NameLast Name
Relationship to the child:
Phone

Area CodePhone Number
Name

First NameLast Name
Relationship to the child:
Phone

Area CodePhone Number
Name

First NameLast Name
Relationship to the child:
Phone

Area CodePhone Number
Legal
YesNo
If yes, please explain:
Does your child have an IEP, academic or emotional or any other needs that we should know about?*
YesNo
If NO, the following action should be taken: If you wrote Yes above type N/A*
Program Permission and Authorization Form

school year 2021-2022
I give permission
I give permission
I give my permission
I give permission
I understand.
I understand.
I understand
I understand
I understand
I understand
I understand
I will be there at 6:30 and I will pick up a hot family meal
I understand
I understand
I understand
I agreeI cannot make this commitmentOther
I agreeI do not agree
Home Life and Hobbies

More about my Child
My child is happiest when s/he is blanks . His/her favorite thing about school is blank .
At home my child likes to blanks. My child is good at blank .
Additional Information
Does your family have religious or cultural traditions and practices we should know about to better care for your child?
Is there anything else that you'd like us to know about your Child or your family?
This information is true and correct to the best of my knowledge and information. Signature
Should be Empty:

Student Enrollment form

Parent/ Guardian Information

Emergency Contact Information

Medical

Availability- Time Commitment

Dismissal Instructions

Legal

Program Permission and Authorization Form

Home Life and Hobbies

Additional Information