SMCSD Student Registration Form for After School Program

Student Additional Information
Student Gender
Primary Language/s Spoken at Home
Student School
Student Grade
Student Ethnicity
Has the student ever been in Bridge the Gap?
Does your child have an Individualized Education Plan (IEP)?
Does your child receive any school support services?
If yes, please describe the services your child receives:
Does your student participate in any extracurricular activities (sports, classes, clubs, or programs which might interfere with Bridge the Gap College Prep scheduling?
If yes, please list the extracurricular activities:

Additional Family Information

The following information is used for Program Grant and Scholarship Purposes ONLY. This information is aggregated and can not be used to identify you.
Does your child have additional siblings?
Did your child qualify for free/reduced priced lunch at school?
List the name, grades, and schools of your child's siblings.

Parent/Guardian Information
Parent/Guardian #1 Name

First NameLast Name
Parent/Guardian #1 Email
example@example.com
Parent/Guardian #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Relationship to Student
Parent/Guardian #1 Address the Same as Students?

Additional Parent/Guardian Information
Parent/Guardian #2Name

First NameLast Name
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Relationship to Student
Parent/Guardian #2 Address the Same as Students?

Emergency Contact/Authorized Persons Information

When I am unable to pick my child up or we are unable to reach you, I give the After School Program staff permission to contact and/or release my child to the following contact.
Emergency Contact/Authorized Persons

First NameLast Name
Emergency Contact Email
example@example.com
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship to Student

Emergency Medical Release
Please describe student food allergies or medications
I confirm that I have: (1) read and reviewed this Emergency Medical Release Form, (2) completed and submitted this additional form with all missing information to a staff member, and (3) made any necessary corrections.
I understand that it is my responsibility to advise BTG of any further changes to the Emergency Medical Release Form.

Internet Access and Photo Release Agreement
I acknowledge that I have carefully read and understand the Internet Access and Photo Release Agreement and have made any necessary corrections. I agree to each of the terms and acknowledgments in the linked waiver, and agree to permit my child to participate in all media releases and technology use during the school year.
I acknowledge that I have carefully read and understand this Photo Release Form and have made any necessary corrections. I agree to each of the terms and acknowledgments in the linked agreement.

Academic Release and Consent for Mutual Exchange of Student Information and Media Release
Please read the "Academic Release Waiver" and sign here.
I acknowledge that I have carefully read and understand this Academic Release and Consent for Mutual Exchange of Student Information and Media Release and have made any necessary corrections. I agree to each of the terms and acknowledgments in the linked agreement.
Should be Empty:

SMCSD Student Registration Form for High School Enrollment