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 NameMiddle NameLast Name

Birth Date*

MonthDayYear

Gender*

Grade entering in Fall 2021*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact E-mail-1*

Contact E-mail - 2*

example@example.com

Phone Number - 1*

Area CodePhone Number

Phone Number - 2*

Area CodePhone Number

School Attending*

Do you require pick up from school?*

Parent's Name*

First NameLast 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.*

YesNo

Please initial below by typing your first name*