T.H.E. After School Program Student Enrollment Form

Today's Date

How many scholars are you enrolling today?

Fields with an asterisk (*) are required. Please note that we may use the information you provide to us on this form to communicate further with you (including to send you promotional materials about the Children’s Defense Fund). For more information about how we collect, use, and share information, please see the Privacy Policy on our website www.childrensdefense.org.

CHILD #1 INFORMATION

Child's Last Name

First Name

Middle Initial

Birth Date

Age

Home Street Address

City

State

Zip Code

Child’s Level

Level I (grades K-2) Level II (grades 3-5) Level III (grades 6-8) Level IV (grades 9-12)

Preferred pronoun

She He They Other

What is your child’s reading proficiency level?

Child’s Race/Ethnicity (select all that apply)

Is your child an English Language Learner? (English is not their first language)

Yes No

Please list any languages your child speaks at home

Grade in the 2022-2023 school year

Does your child receive or qualify for free/reduced price lunch at school during the academic school year?

Yes No

Child’s School Name

City

State

Zip Code

Has your child ever attended a CDF Freedom Schools® Summer or After-School program before?

Yes No

If yes, how many years has your child participated in the CDF Freedom Schools program?

Does your child have health insurance?

If yes, what is your child’s health insurance carrier?

Medicaid Other N/A

Has your child ever qualified for an Individual Educational Plan (IEP) or 504 plan?

What are some strategies our team can use to best support your child's learning throughout the program? (ex: needs additional reading help, prefers small groups)

Does your child have any allergies or health conditions of which we should be made aware? If yes, what?

Is there anything else that you would like to share about your child?

CHILD #2 INFORMATION

Child's Last Name

First Name

Middle Initial

Birth Date

Age

Home Street Address

City

State

Zip Code

Child’s Level

Level I (grades K-2) Level II (grades 3-5) Level III (grades 6-8) Level IV (grades 9-12)

Preferred pronoun

She He They Other

What is your child’s reading proficiency level?

Below Grade Level At Grade Level Above Grade Level Unsure

Child’s Race/Ethnicity (select all that apply)

Is your child an English Language Learner? (English is not their first language)

Please list any languages your child speaks at home

Grade in the 2022-2023 school year

Does your child receive or qualify for free/reduced price lunch at school during the academic school year?

Yes No

Child’s School Name

City

State

Zip Code

Has your child ever attended a CDF Freedom Schools® Summer or After-School program before?

If yes, how many years has your child participated in the CDF Freedom Schools program?

Does your child have health insurance?

Yes No

If yes, what is your child’s health insurance carrier?

Medicaid Other N/A

Has your child ever qualified for an Individual Educational Plan (IEP) or 504 plan?

IEP 504 No

What are some strategies our team can use to best support your child's learning throughout the program? (ex: needs additional reading help, prefers small groups)

Does your child have any allergies or health conditions of which we should be made aware? If yes, what?

Is there anything else that you would like to share about your child?

CHILD #3 INFORMATION

Child's Last Name

First Name

Middle Initial

Birth Date

Age

Home Street Address

City

State

Zip Code

Child’s Level

Level I (grades K-2) Level II (grades 3-5) Level III (grades 6-8) Level IV (grades 9-12)

Preferred pronoun

She He They Other

What is your child’s reading proficiency level?

Below Grade Level At Grade Level Above Grade Level Unsure

Child’s Race/Ethnicity (select all that apply)

Is your child an English Language Learner? (English is not their first language)

Yes No

Please list any languages your child speaks at home

Grade in the 2022-2023 school year

Does your child receive or qualify for free/reduced price lunch at school during the academic school year?

Yes No

Child’s School Name

City

State

Zip Code

Has your child ever attended a CDF Freedom Schools® Summer or After-School program before?

Yes No

If yes, how many years has your child participated in the CDF Freedom Schools program?

Does your child have health insurance?

Yes No

If yes, what is your child’s health insurance carrier?

Medicaid Other N/A

Has your child ever qualified for an Individual Educational Plan (IEP) or 504 plan?

IEP 504 No

What are some strategies our team can use to best support your child's learning throughout the program? (ex: needs additional reading help, prefers small groups)

Does your child have any allergies or health conditions of which we should be made aware? If yes, what?

Is there anything else that you would like to share about your child?

FAMILY INFORMATION

Last Name of Adult completing this form

First Name

Middle Initial

Relationship to Child(ren)

Parent Grandparent Other relative Other (non-relative)

Is this person the child(ren)’s a legal guardian?

Yes No

Preferred pronoun

She He They Other

Home Phone Number

Mobile Phone Number

Work Phone Number

Email Address

Alternate Email Address (if applicable)

How many people live in the household?

# of children aged 6-18

# of children 5 and under:

Yes No

EMERGENCY CONTACT INFORMATION

Contact Person’s Last name

First Name

Middle Initial

Is this person authorized to pick up the child(ren) you enrolled in the program?

Yes No

Home Phone Number

Mobile Phone Number

Work Phone Number

Email Address

Alternate Email Address (if applicable)

Please list other adults who are authorized to pick up the child(ren) you enrolled in the program.

Name

Relationship

Mobile Phone #

Name

Relationship

Mobile Phone #

In case of an emergency, I give permission for any of the above individuals to be contacted and my child(ren) may be released to any of them.

Signature

Date

I understand that the organization that is enrolling my child(ren) in the CDF Freedom Schools® program is in partnership with the Children’s Defense Fund to offer this program. This personal information will be kept private and confidential and will only be shared with CDF to collect demographic information on children served and to report out this information in aggregate form.

Signature

Date

CHILD #1 INFORMATION

CHILD #2 INFORMATION

CHILD #3 INFORMATION

FAMILY INFORMATION

EMERGENCY CONTACT INFORMATION

En español:

Formulario de Inscripción para "T.H.E." Programa Extra Curriculares >

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CHILD #1 INFORMATION

CHILD #2 INFORMATION

CHILD #3 INFORMATION

FAMILY INFORMATION

EMERGENCY CONTACT INFORMATION

En español:

Formulario de Inscripción para "T.H.E." Programa Extra Curriculares >

Contact Us

Subscribe to Our Mailing List

Sitemap

Parent's Menu