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- Which program(s) are you interested in? (Check all that apply)*
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- Date of Birth*
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Format: (000) 000-0000.
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Format: (000) 000-0000.
- Preferred Communication Method*
- Should Another Parent/Guardian Receive Communications?*
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Format: (000) 000-0000.
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Format: (000) 000-0000.
- Is this individual authorized to pick up your child from D.A.N.A. Johnson Foundation programs or activities?*
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- Activities your child enjoys*
- Areas where your child could use support or development
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- Are there any challenges, behaviors, circumstances, or concerns that would be helpful for the program team to know?
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- Desired gains from the Young Queens Reading Circle (YQRC)
- Primary reasons for enrolling in L.E.A.P. After-School
- Does the child currently participate in other after-school or extracurricular activities?
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- Reliable transportation available?*
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- Interested in occasional Foundation family activities, workshops, or community events?*
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- Does your child currently have a parent, guardian, close family member, or other significant person in their life who is experiencing or has experienced any of the following? (Select all that apply.)
- If you are comfortable sharing, please tell us the person’s relationship to your child and anything you believe would help us better support your child. Please do not include private information such as military identification numbers, inmate numbers, or other sensitive identifying information.
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- Does the child require reasonable accommodations or additional support?*
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- Acknowledgments*
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- Date*
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- Should be Empty: