Summer School Parent Sign-Up Sheet
Please fill out this form to register your child for the summer program.
Program Schedule: Start Date: June 9, 2026 End Date: July 9, 2026 Tuesday, Wednesday, & Thursdays Time: 8:00 AM – 2:00 PM Early Drop-Off Available: 7:30 AM Cost: $40 Per Week Breakfast and lunch will be included.
Parent's Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Full Name
*
First Name
Last Name
Child's Age
*
Grade Level
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Additional Notes or Questions
HEALTH & MEDICAID INFORMATION
Does your child have any allergies or medical conditions we should know about?
Yes
No
If yes, please explain:
Does your child currently receive Medicaid benefits?
Yes
No
If yes, please provide Medicaid ID Number
If yes, please provide Provider
PROGRAM QUESTIONS
Will your child need early drop-off at 7:30 AM?
Yes
No
PERMISSION & SIGNATURE
Do you consent to your child being photographed and video recorded for program-related use?
*
Yes
No
I give permission for my child to participate in The Optimist Shift Summer Program.
Parent/Guardian Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sign Up
Should be Empty: