Summer 2024 Registration
June, July, and August 2024
Child's name
First Name
Middle Name
Last Name
Child's age
Date of birth
-
Month
-
Day
Year
Date
Child's grade in September 2024
School of attendance
Teacher's name
First Name
Last Name
Select one or more options
Individualized literacy class - 4 weekly 75 min. sessions - $390/mo.
KINDERGARTEN BOOT CAMP - July 16-19 - $180/week
KINDERGARTEN BOOT CAMP - July 23-26 - $180/week
Other
Does child have an IEP? If so, please provide a copy.
Yes
No
Does child have a diagnosis in any of the following categories?
Dyslexia
Learning disability
Hearing
Vision/needs glasses
Speech
Other
Mother's name or other legal guardian
First Name
Last Name
Mother's phone
-
Area Code
Phone Number
Mother's email
example@example.com
Mother's address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's (or other legal guardian's) name:
First Name
Last Name
Other legal guardian's phone
-
Area Code
Phone Number
Other legal guardian's email
example@example.com
Child resides mainly with:
Mother
Father or other legal guardian
Both
Emergency contact person
First Name
Last Name
Emergency contact phone
-
Area Code
Phone Number
1st additional person who may pick up your child:
First Name
Last Name
2nd additional person who may pick up your child:
First Name
Last Name
Please describe your child's current reading abilities/difficulties:
Please describe your wishes/goals for your child's literacy development:
Are there any physical, behavioral, or mental health conditions that may impact your child during this program? Please describe.
Does your child have any special dietary requirements or food allergies?
What are some of your child's interests?
Is there anything else you'd like us to know about your child?
What are your child's schedule limitations?
Do we have permission to take photos and videos of your child in connection with reading lessons he/she is engaged in? We may use them for promotional and educational purposes in print or on social media WITHOUT an accompanying name.
Yes
No
By submitting this form, I acknowledge/understand that:
I've read RFL's Summer 2024 Parent Guidebook and agree to the terms of enrollment.
If a charter school is paying my child's fees, I must submit a request for services for my child's classes for each month before the month begins. If the charter school doesn't pay Reading For Life for any reason, cost of enrollment is my responsibility.
I must pay a $30 enrollment fee to hold my child's spot in the summer program. This amount is due at the time this registration form is submitted. It is not payable by the charter schools. It's not refundable for any reason.
Select the option you'll use for payment:
Venmo: Deva-Deveaux
Cash
Check made out to: Reading For Life
By signing I represent that I am the parent or legal guardian of the child being enrolled, and have full legal authority to register the child in the RFL program and to determine and designate the emergency contact for the child, as well as those persons authorized to pick up the child.
Submit
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