Child Enrollment Form 2010 | the Simple Room

Your name: *

Child's name: *

Child's date of birth: *

Preferred name/nickname:

Gender: *

Male

Female

Relationship to this child: *

Parent

Foster Parent

Legal Guardian

Grandparent/Relative

Is this child living with you?: *

Yes

Program Information

Has the child attended a Simple Room program before?: *

Yes

If yes, how many year(s)/summer(s) has the child participated in a Simple Room program?:

Other program details:

How did you hear about The Simple Room and/or the program(s) for which you are registering for your child?:

General Information

Child's race/ethnicity: *

Do any of your children receive free/reduced price lunches at school during the school year?: *

Yes

How many people live in your household?: *

How many children live in your household?: *

School: *

Grade enrolled in 2009-2010: *

Reading level:

Was the child in special education during the 2009-2010 school year?: *

Yes

Has the child ever repeated a grade?: *

Yes

Has the child attended a Simple Room summer program before?: *

Yes

If yes, how many summers has the child participated in a Simple Room program (not including the current summer)?:

Emergency Contact Information

Emergency contact (if parent or guardian cannot be reached):

Emergency contact name: *

Emergency contact relationship to child: *

Emergency contact home phone:

Emergency contact work phone:

Emergency contact cell phone:

Parent/Guardian name:

Parent/Guardian relationship to child:

Parent/Guardian street address:

Parent/Guardian city:

Parent/Guardian state:

Parent/Guardian zip code:

Parent/Guardian occupation:

Parent/Guardian highest grade completed/degree earned:

Parent/Guardian home phone:

Parent/Guardian work phone:

Parent/Guardian cell phone:

Parent/Guardian email:

Does the child live with this parent or guardian?:

Yes

Parent/Guardian name:

Parent/Guardian relationship to child:

Parent/Guardian street address:

Parent/Guardian city:

Parent/Guardian state:

Parent/Guardian zip code:

Parent/Guardian occupation:

Parent/Guardian highest grade completed/degree earned:

Parent/Guardian home phone:

Parent/Guardian work phone:

Parent/Guardian cell phone:

Parent/Guardian email:

Does the child live with this parent or guardian?:

Yes

Medical Information

During the past 12 months, have you been told by a doctor or health professional that this child has any of the following conditions?:

Hay fever or any kind of respiratory allergy

Any kind of food or digestive allergy

Eczema or any kind of skin allergy

Frequent or severe headaches, including migraines

Stuttering, stammering or other speech problems

None

Please list any allergies:

Does this child currently need or use medicine prescribed by a doctor?: *

Yes

If yes, please list the medication(s):

Is this child limited or prevented in any way in his/her ability to do the things most children of the same age can do?: *

Yes

If yes, please explain:

Has this child been to the doctor for any reason in the last 12 months?: *

Yes

Has this child been to the dentist in the last 12 months?: *

Yes

Does this child have health insurance?: *

Yes

If yes, complete the next 4 questions:

Health insurance carrier:

Name of policy holder:

Health insurance identification number:

Health insurance group number:

Please explain any special procedures that should be followed in the event of a medical emergency: