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ELOP 2023-2024 Enrollment Form - Intersession

2023-2024

Expanded Learning Opportunities Program (ELOP)

Enrollment Form for Intersession

(Please fill out a seperate form for each child)

Please complete the form below. Required fields marked with an asterisk *

Student Name:*

Answer Required

Birthdate:*

Answer Required

Age:*

Answer Required

Grade:*

Answer Required

Teacher's Name:*

Answer Required

Address

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

Parent/Guardian Name #1:*

Answer Required

Parent/Guardian #1 Phone Number:*

Number Required

Parent/Guardian Name #2:

Answer Required

Parent/Guardian #2 Phone Number:

Number Required

Sign-Out Information:

Safety is the top priority in the program, therefore, no child enrolled will be released from the ELOP without a parent/guardian signature or that of one of the three individuals listed below (Note: The names that appear below must be of someone 16 years or older).

Name:*

Answer Required

Phone Number:*

Number Required

Relationship:*

Answer Required

Name:

Answer Required

Phone Number:

Number Required

Relationship:

Answer Required

Name:

Answer Required

Phone Number:

Number Required

Relationship:

Answer Required

Parent/Guardian Signature:*

Signature Required

Confirmation Email

Confirmation Email *

Email Required