Project Impact - Summer Program 2009 Registration Form

Please complete the Registration Form below and submit it. Then print out the attached Permission Form, and bring a signed copy to the School Site Coordinator.

* My child will attend
Session 1: June 15-July 2, 2009
Session 2: July 13-30, 2009
Both Sessions

* Last Name

* First Name

* Feeder School

* Grade Level

* Ethnicity (Please check one or more as needed)
American Indian/Alaskan Native
Black or African American
Hispanic or Latina(o)
White or Caucasian American
Unknown
Cannot Answer

* Age in Years

* Birth Date (month/day/year)

* Gender
Male
Female

* Limited English Proficiency
Yes
No

* Free or Reduced Lunch
Yes
No

* Identified with Special Needs or Disability
Yes
No

If Yes above, please explain

Student registering for Credit Recovery Course
Yes
No

Course Needed:

Family Information

* Last Name

* First Name

* Relationship
Parent
Guardian

* Single Family Home
Yes
No

If Yes above, headed by
Male
Female

* Address

* City

* Zip

* Home Phone

Work Phone

Student Address (if different from parent/guardian):

Parent or Guradian Phone

Student Phone (If different)

* How will the student be transported TO the program site?
On school property (no transportation)
Rode school bus
Walked or biked to the site alone
Walked or biked to the site with friends
Walked to site by teacher or staff member
Brought by parents or relatives
Brought by friend or neighbor
Other (please specify below)

Other transportation to the program site

* How will the student be transported FROM the program site?
Rode School bus
Walked or biked home alone
Walked or biked home with friends
Walked home by teacher or staff member
Picked up by parent, relative, or guardian
Picked up by friend or neighbor
Other(please specify below)

Other transportation from the program site

OTHER PERSONS AUTHORIZED TO PICK-UP STUDENT

* Name (1)

* Phone (1)

* Relationship to Student (1)

(1)
Emergency Contact
Authorized Pickup

Name (2)

Phone (2)

Relationship to Student (2)

(2)
Emergency Contact
Authorized Pickup

Name (3)

Phone (3)

Relationship to Student (3)

(3)
Emergency Contact
Authorized Pickup

Doctor Name

doctor Phone

Permission for Treatment by Doctor/Hospital
Yes
No

* Health Insurance
Yes
No

If YES, please list insurance Carrier

Policy #

Group #

Serious Health Problems
Yes
No

If YES, please explain

Medications
Yes
No

If YES, please explain

Physical Description: Eye Color

Hair Color

Height

Weight

Special dietary needs or allergies
Yes
No

If YES, please explain

* NAME OF SCHOOL SITE:
Apalachicola Bay Charter School
Franklin County School
City of Apalachicola

* Required