'25-'26 Enrichment Program Enrollment Form

Enrichment Program Year '25-'26

Enrollment Form
One enrollment form per student. Thank you.
Program Option*
Student Legal Name*

First NameLast Name
Student Preferred Name/Nickname
If they do not use one, please leave blank
Student Birthday*

MonthDayYear
Date
Student Current Grade*
Parent Name*

First NameLast Name
Parent Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Does the student have/need an IEP or 504 Plan?*

YesNo
If yes, please describe the IEP or 504 Plan
Please submit copy of plan after enrollment approval.

Emergency Notification Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Student*
Please list all adults who are allowed to drop off/pick up student.
Valid, current ID will be needed for pick ups.

Does the Student have any food allergies?*

YesNo
If yes, please describe/list foods.
Does the student have any medical conditions/needs?*

YesNo
If yes, please describe.
Will the student require any medication during the day?*

YesNo
If yes, please describe.
There is no licensed nurse on staff - so parents would have to come and administer the medication.

What are your students interests and/or hobbies?
Do you have any educational concerns or subjects that your student needs more help on?*

YesNo
If yes, please describe.

Registration Fee
There is a annual registration fee of $25 per family.

It is due before the start date. It can be paid online or in person (at the center).
Registration Fee Payment Type*
I acknowledge that the registration is due before the start date:*

YesNo

Charter Info
Are you using charter school funds?*

YesNo
Name of School?*
If school is not listed, what school are you currently with?
If we are not a current vendor with your charter school, please contact your teacher to add us as a vendor. If we become a vendor with your school, there will be no out of pocket costs to you each month.

Your school will need the following info:

34th St Prep Academy
15356 La Paz Dr #4
Victorville, CA 92395
info@34prep.com
442-866-9022

Breanna Humes - Owner
Current Charter Teacher
Charter Teacher email.
example@example.com
Should be Empty: