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PREP High School Program Registration
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PREP High School Program Registration
PREP Registration Form
PROGRAM INFORMATION
Program Update
In the event that we are unable to provide our PREP program on campus, tutoring and activities will take place online via Google Classroom. En el caso de que no podamos ofrecer nuestro programa PREP en la escuela, la tutoría y las actividades se llevarán a cabo en línea a través de Google Classroom.
Equal Opportunity
LEARN is an Equal Opportunity Non-profit Organization committed to providing all employees and program participants an environment free of discrimination and harassment regardless of race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate.
STUDENT INFORMATION
Student's School Name
*
Please Select School
South El Monte High
Arroyo High
Rosemead High
Mountain View High
Ledesma High
Whittier High
El Monte High
Frontier High
Pioneer High
ID Number (Student IDN)
*
Student Name
*
First
Middle
Last
Student Gender
*
Male
Female
Other
Student Grade Level
*
This is the grade the student will be GOING INTO for Fall 2020.
9
10
11
12
Student Date of Birth
*
(mm/dd/yyyy)
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Student Age
*
Student Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Student Daytime Phone Number
*
Student Evening Phone Number
*
Student Mobile Phone Number
Student Email
PARENT/GUARDIAN INFORMATION
Parent/Guardian #1 Name
*
First
Last
Parent/Guardian #1 Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Parent/Guardian #1 Home Phone Number
*
### - ### - ####
Parent/Guardian #1 Mobile Phone Number
*
Parent/Guardian #1 Email
*
Enter Email
Confirm Email
Parent/Guardian #2 Name
First
Last
Parent/Guardian #2 Address
(If different from Parent/Guardian #1)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Parent/Guardian #2 Home Phone Number
### - ### - ####
Parent/Guardian #2 Mobile Phone Number
Parent/Guardian #2 Email
STUDENT HEALTH HISTORY & INFORMATION
Medications
*
Medical Conditions
*
Allergies
*
Primary Care Physician's Name
*
Primary Care Physician's Phone Number
*
### - ### - ####
Health Insurance or Health Plan Provider
*
Health Policy/Plan Number or Member ID
*
Emergency Contacts
Emergency Contact #1 - NAME
*
First
Last
Emergency Contact #1 - HOME PHONE NUMBER
*
### - ### - ####
Emergency Contact #1 - MOBILE PHONE NUMBER
*
### - ### - ####
Emergency Contact #2 - NAME
*
First
Last
Emergency Contact #2 - HOME PHONE NUMBER
*
### - ### - ####
Emergency Contact #2 - MOBILE PHONE NUMBER
*
### - ### - ####
PROGRAM DESCRIPTION & GUIDELINES
I understand that my child has the opportunity to attend the PREP after-school program activities Monday – Thursday, from the end of the school day until 6:00 PM. On minimum days the program will end 3 to 4 hours after the school day ends. Program operating hours and offerings may vary. Contact your Site Coordinator for the most current schedule. Yo entiendo que mi hijo/a tiene la oportunidad de asistir actividades del programa PREP de lunes a jueves, desde el fin del día escolar hasta las 6:00 PM. En los días mínimos el programa operara de tres a cuatro horas después del termino de clases. CONSENT TO USE OF VIDEO OR PHOTOGRAPHY/ ACUERDO DE USO DE VIDEO O FOTOGRAFIA: My signature below authorizes the PREP staff to photograph and/or film my child during the program and I hereby consent to use of these photographs in LEARN’s promotional material. Mi firma abajo autoriza al personal de PREP para tomar fotos y/o video de mi hijo/hija durante el programa y yo permito el uso de las fotos en materia promocional de la organización LEARN. RELEASE OF INFORMATION/ INTERCAMBIO DE INFORMACION My signature below authorizes the exchange of information regarding my child’s academic progress between the PREP staff and the staff at my child’s school. Mi firma abajo autoriza el intercambio de información sobre mi hijo y su progreso académico entre el personal de PREP y el personal de la escuela de mi hijo. LIABILITY WAIVER/ LIBERACION DE RESPONSABILIDAD: I hereby waive all claims against my child’s school district, the LEARN organization and its employees for injury, accident or illness occurring by reason of participation in the PREP Program. In case of an emergency, I authorize any licensed physician or hospital to render such medical aid as may be deemed necessary and/or desirable. Any cost/liability incurred for such treatment shall be my sole responsibility. Por el presente yo renuncio todos reclamos contra el distrito escolar de mi hijo/a, la organización LEARN y sus empleados por heridas, accidentes o enfermedades ocurriendo por razón de participar en el programa PREP. En caso de emergencia, yo autorizo cualquier medico o hospital licenciado para rendir asistencia medica como sea necesario o deseable. Cualquier costo/responsabilidad incurrido por tal tratamiento será mi responsabilidad única.
DIGITAL SIGNATURE OF PARENT OR LEGAL GUARDIAN
After clicking the SUBMIT button below, you will be automatically redirected to a page where you will review the information you entered and electronically sign the completed registration form. After signing, you will be able to save and print a copy of the signed form, in addition to being emailed a PDF copy of the form.
Comments
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2017 L.E.A.R.N.
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