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)?

YesNo
Does your child receive any school support services?

YesNo
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?

YesNo
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?*

YesNo
Did your child qualify for free/reduced priced lunch at school?*

YesNo
List the name, grades, and schools of your child's siblings.

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 Name Last Name
Emergency Contact Email*
example@example.com
Emergency Contact Phone Number*
Please enter a valid phone number.
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.*

I AgreeI Disagree - I will contact BTG to give more information.

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.*

I AgreeI Disagree

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.*

I AgreeI Disagree
Should be Empty:

SMCSD Student Registration Form for High School Enrollment