Student Support Program - Student Contact Information

Please complete the student contact information for each child that will be attending the Student Support Program. You will only need to complete this form once. Completing this form does not register a child. The program is a drop-in program servicing students on a first-come, first-serve basis.

Student Information

The student must be enrolled in their Local School District. Please write the name of his/her district.

Please select the grade level your child is in for the 2020-2021 school year.

Please list all allergies below. Notes below are for informational purposes only. Staff cannot administer any medications or guarantee an allergy free environment. If you have any concerns, speak to a staff member at the time of drop-off.

Parent Enrolling Student

Parent #2 Information


If different than above.

Emergency Contact #1

Emergency Contact #2


By checking the box, you are agreeing to each term set forth.


Selecting days below does not register or guarantee your student a spot on those days.

Electronic Signature

This provides a digital signature certifying that, to your knowledge, all above information is accurate and accepts all agreements within this form.