IKIDZ : 2018-2019 AFTERSCHOOL REGISTRATION FORM

IKIDZ- MOWRY: IN-PERSON REGISTRATION FOR GRADES K-6

5133 Mowry Avenue, Fremont, CA 94538

SCHOOL YEAR 2021-2022

Classes begin August 2021

Registration begins January 2021

Student Name *

First Name Middle Name Last Name

Birth Date *

Month Day Year

Gender *

Grade entering in Fall 2021 *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Contact E-mail-1 *

Contact E-mail - 2 *

example@example.com

Phone Number - 1 *

Area Code Phone Number

Phone Number - 2 *

Area Code Phone Number

School Attending *

Do you require pick up from school? *

Parent's Name *

First Name Last Name

Emergency Contact Information (other than parents listed in the form) Include Name, Phone number *

List names of people who are authorized to pick up your child from the center. *

Physician's Contact Information in case of emergency *

Any allergies or medical conditions that we need to know about *

We acknowledge that we will comply with the school policies including CDC guidelines and requirements for our child to attend school. *

Yes No

Please initial below by typing your first name *