Reading Foundations Enrollment Form

Reading Foundations - 2nd Semester

Enrollment Form
Reading Foundations
This is a semester long class that takes place on Fridays from 10 am to 12 pm (Noon). In this class we focus on learning to read and reading strategies. Each child will be assessed on the first class and a tailored learning path will be created for them.
How many students are enrolling?
Student #1 Legal Name*

First NameLast Name
Student #1 Birthday*

MonthDayYear
Date
Student #2 Legal Name

First NameLast Name
Student #2 Birthday

MonthDayYear
Date
Student #3 Legal Name

First NameLast Name
Student #3 Birthday

MonthDayYear
Date
Do any students have a preferred name (that is different from their legal name)?
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.

Reading Foundations - 2nd Semester