2014 Application for Rising Pre K
Summer Enrichment Programs June 9 – July 10, 2014
Directions: Please complete all sections of this application and return it directly to the Federal Programs Department at Central Office (Room 404). You can also fax it to (205) 231-4203 or (205) 231-2925. If you have questions please call (205) 231-4615 or (205) 231-2409.
Name Date / /
Last First MI
Home Address: Telephone #
Student #
Current School: Current Grade: Special Education yes no
Parent(s) Name: Cell: Work:
School to attend during the 2014-2015 school year
If your child is served by an IEP or PEP please submit a copy to the assigned summer location.
In case of Emergency, contact:
1. Relationship Phone
2. Relationship Phone
Medical Information: (Allergies, nose bleeds, bites, etc.) Yes No
If yes, please explain nature of the problem
Physician’s Name: Phone:
Parent’s Signature: Phone:
Please select the school of your choice. If space is available you will receive a letter of acceptance. This letter should be returned to us by the date indicated for confirmation of attendance. The hours of operation are 8:00am – 1:00pm Monday – Thursday. We will be closed July 3-4, 2014.