2023 SUMMER CAMP QUICK REGISTRATION FORM

CITY OF HALLANDALE BEACH HUMAN SERVICES DEPARTMENT 2023-24 ASP

Interest Form
Name*

First NameLast Name
Last 4 numbers of Student's Social#*
*If student has no social enter year of birth as last 4 SSN
Date of birth*

MonthDayYear
Date
Age*
Gender*
2023-24 School Year Current Grade*
Student Number- 06*
10 digit number begins with 06
RACE/ETHNICITY
Race/Ethnicity*
Current School name*
Home Address *
City*
Zip code*
Number of people living in home*
# of people living in home
Annual Household Income*
Gross income for all working adults 18+ i.e. Gross Monthly Income $1000 x 12 Months = $12,000 + $506 Food Stamps x 12 Months = $6,072 + $904 Social Security Disability x 12 Months = $10,848
Passcode*
4 digit code -for dismissal
Mother's name *

First NameLast Name
Mother's name
PHONE (Mobile)*

Area CodePhone Number
Mother's place of employment
Mother phone (Work)

Area CodePhone Number
SS#
Father name
Father's name *

First NameLast Name
Father phone (Mobile)

Area CodePhone Number
Father's place of employment
Father phone (work)

Area CodePhone Number
Father phone (Work)

Area CodePhone Number
SS#
HOURS
HOURS
MOBILE PHONE

Area CodePhone Number
PHONE

Area CodePhone Number
Parent's Email*
example@example.com
FATHER'S E MAIL
example@example.com
RELATIONSHIP
Emergency Contact *
Emergency Contact Phone #*
Does this student have an Individualized Education Plan (IEP)?
Does your child have any special needs/disability or required special accommodations?
Please provide any information necessary for our staff to provide excellent services to your child
Emergency Contact Phone #

Area CodePhone Number
II. LIST INDIVIDUAL(S) AUTHORIZED TO PICK UP CHILD:

NAME

PHONE

AGE

RELATIONSHIP
PARENT SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Social Worker verified a copy of student's Birth Certificate is in the file. Social Worker verified a copy of student's Social Security Card is in the file. Notes/Special Instructions:
HSD-YS-13 EFF.05/07 - Revised 4/30/08

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CITY OF HALLANDALE BEACH HUMAN SERVICES DEPARTMENT 2023-24 ASP