Hannah Freedom School

July 2-August 3, 2018

PARENT NAME______DATE______

STUDENT INFORMATION – Please print or type Legibly

Last Name______First Name______

Gender: ?  Female Male AGE______Date of Birth______Grade______

Child’s Nickname/Preferred Name______Primary Language Spoken______

RACE/ETHNICITY (Check All That Apply)

African American/Black

American Indian or Alaskan Native

Asian, Native Hawaiian or Pacific Islander

Hispanic/Latino

White/Non-Latino

Other

Do any of your children receive or qualify for free/reduced lunch during the school year

Yes  No

How many people live in your household? _____

How many children live in your household? _____

Annual household Income: $______

Name of School______

Address of School______

TYPE OF SCHOOL

Public

Charter School

Faith-Based

Private

Home

Does your child participate in any of the following programs?

Bilingual Education

ESL/ELD
Special Education

Gifted /Talented

Other

Does your child have any academic challenges? If so, please describe. ______

Does your child have any behavioral challenges? If so, please describe. ______

What activities does your child participate in during the school year? (e.g. sports, music, art, tutoring)

______

Is the student in foster care?  Yes  No

_

What type of activities is your child interested in?

Has child been previously enrolled in Freedom School? ___Yes _____No

Does your child have siblings? ___Yes ____No

Does your child have siblings who have participated in Freedom School? ___Yes ___No

Name of sibling ______

Year participated______

______

For reasons related to field trips, please answer the following:

Does your child know how to swim? ____Yes___ _No

Does your child know how to ride a bike? ___Yes____ No

T-Shirt size___ YS (6-8) ___YM (10-12) __YL (14-16) Adult: ___S___M__L__XL

Medical Information

Does your child have any health problems? Specify below.

______

What food(s), if any, is your child allergic to?

______

Please list any other allergies:

______

Does this child use any type of medication prescribed by a doctor? Please list:

______

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, including physical exercise?

Yes No

______

Has this child been to the doctor for any reason in the last 12 months?Yes No

Explain______

Has this child been to the dentist in the last 12 months? Yes No

Please explain ______

Does this child have health insurance?

Yes No

Health Insurance Carrier: ______Name of Policy Holder: ______

Identification Number: ______Group Number: ______

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

Has a doctor, health professional, teacher, or school official ever told you that this child has a learning disability?  Yes  No

If yes, please explain:

______

PARENT INFORMATION

Mother/Guardian______

First Name Middle Name Last Name

Number and Street______

City ______State ______Zip Code ______

Occupation ______Highest Grade Completed or Degree Earned ______

Home Phone (____) ____ - ______Work Phone (____) ____ - ______

Cell Phone (____) ____ - ______Email: ______

Father/Guardian ______

First Name Middle Name Last Name

Number and Street ______

City ______State ______Zip Code ______

Occupation ______Highest Grade Completed or Degree Earned ______

Home Phone (____) ____ - ______Work Phone (____) ____ - ______

Cell Phone (____) ____ - ______Email: ______

With whom does child reside? ______

Emergency Contact (If parent or guardian cannot be reached):

Name ______

Home /Work#______Cell #______

Name ______

Home /Work #______Cell #______

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Other adults authorized to pick up your children:

Name______Relationship______

Phone Number______

Name______Relationship______

Phone Number______

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How did you hear about this program?

______

About Hannah Freedom School

The Hannah Freedom School (HFS)is not an ordinary summer program. It is a fun, five week culturally rich experience for students who have recently completed the 3rd - 8th grades. Built around literacy enrichment, HFS features a model curriculum for reading enrichment, youth leadership development, cultural awareness, parent empowerment, civic engagement, and social action. In partnership with the faith community, schools, and partner organizations, HFS enhances children’s motivation to read and generates positive attitudes towards learning. Afternoons are devoted to fostering student creativity and exploration in performance and visual arts, the outdoors, sports, science.

The goal of Hannah Freedom School is to:

  1. Excite students about reading and learning;
  2. Maintain or improve reading skills and comprehension over the summer;
  3. Establish reading as a leisure time activity;
  4. Build self-awareness and esteem;
  5. Build cultural awareness and appreciation;
  6. Provide an opportunity for self-expression and creativity; and
  7. Provide college role models

Parents play a huge role in the HFS experience and are required to attend weekly parent meetings, volunteer to assist with at least one event; ensure that their children arrive every day on time; and inform HFS staff if their child will be absent or unable to complete the full summer program.

To enroll your child.

Please complete the attached form.

Return application to the Hannah Project (200 Gate 5 Road Suite 205 Sausalito, CA 94965) or Bayside/MLK School by May 1st - Priority Enrollment.

Schedule 30 minutes required pre-enrollment meeting.


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