Roberts Extended Day Enrichment Program
Registration Form
CHILD’S NAME:
BIRTH DATE: / / AGE: GRADE:
GENDER: __M __F ETHNICITY__________________ TEACHER:
PARENT NAME:
EMPLOYER: WORK PHONE: ( )
HOME PHONE: ( ) - CELL PHONE: ( )
PARENT NAME:
EMPLOYER: WORK PHONE: ( )
HOME PHONE: ( ) - CELL PHONE: ( )
The following individuals are allowed to pick up this child and may be contacted in case of an emergency:
EMERGENCY CONTACTS DAY PHONE RELATIONSHIP
( ) -
( ) -
List any medications, allergies or limitations requiring special attention:
My child may be in photographs or videos taken during the program: __Yes __No
My child may ride on a Leon County School Bus for prearranged field trips: __Yes __No
My child may watch G and PG rated movies: __Yes __No
It is clear that I must have my payment in the EDEP office on or before the payment due date or a $20.00 late charge will be assessed. My fee will be paid on time even if my child does not attend on the actual due date.
PARENT SIGNATURE: DATE: