ECNC 2023 Freedom Schools Child Enrollment Form

East Cleveland Neighborhood Center Freedom Schools Child Enrollment Form
Complete an enrollment form for each child. If enrolling more than one child from the same family/household complete a separate form for each child.

If you have any questions contact

Ms. Shalonda,

Freedom School Registration Coordinator at

216-932-3626 or sswanson@ec-nc.org
Child's Information
Date*

MonthDayYear
Date
Name*

First NameLast Name
Birth Date:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
T-Shirt Size *
Gender Identity: Preferred pronouns:*
Child's Race/Ethnicity (check all that apply)*
Please list any languages your child speaks at home*
Is your child a English Language Learner? (English is not their first language)*

YesNo
Type of school that child attended this past school year:*
Grade just completed*
Does your child receive or qualify for free/reduce lunch at school during the academic school year?*

YesNo
What school does your child attend? *

Superior Elementary, East Cleveland, OhioCaledonia Elementary, East Clevealnd, OhioMayfair Elementary, East Cleveland, OhioKirk Middle School, East Cleveland, OhioShaw High School
Does your child have health insurance, if Yes who is your child's health insurance carrier?

YesNoMedicaid
Has your child ever particpated in Special Education or had a 504 Plan?

Yes, Special EducationYes, 504 PlanNo
Has your chlild attend a CDF Freedom Schools Summer program*

YesNo
If Yes, how many years has your child participated in the CDF Freedom Schools summer program? *
Does your child have any allergies or health conditions of which we should be made aware of? If yes, what?*
Is there anything else you would like to share about your child?*
What are some strategies our team can use to best support your child's learning throughout the summer? (Ex: Needs additional reading help, needs assistance with technology)
Name of person completing this form*

First NameLast Name
Gender Identity: Preferred pronouns:*
Relationship to child(ren)*
Phone Number*

Area CodePhone Number
Email Address:*
example@example.com
Alternate Email Address (if applicable):*
example@example.com
How many people live in your house hold? *
How many children in your house hold are between the ages of 6-18 .*
How many people live in your houehold?*
How many children in your household are 5 and under?*
Emergency Contact Information
Emergency Contact Name:*

First NameLast Name
Phone Number*

Area CodePhone Number
Email Address:*
example@example.com
Is this person authorized to pick up the child(ren) you enrolled in this program? *

YesNoN/A
Please list the Name, Relationship, and Phone Number of an adult authorized to pick up the child(ren)? *
In case of an emergency, I give permission for any of the above individuals to be contacted and my child(ren) may be released to any of them.
Signature*

Clear
I understand that the organization enrolling my child in the CDF Freedom Schools program is in partnership with the Children's Defense Fund to offer this summer program. This personal information will be kept private and confidential and will only be shared with CDF to collect demographic-served information and to report the information in aggregate form.
Signature*

Clear
Should be Empty:

East Cleveland Neighborhood Center Freedom Schools Child Enrollment Form

Child's Information

Emergency Contact Information