Hilldale BOOST Enrollment Form 2015-16

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Student Name/Nombre del Estudiante *

Grade/ Grado *

3rd Grade

4th Grade

5th Grade

Teacher/ Maestro

Birthdate/Fecha de Nacimiento *

YYYY

My child has permission to walk home/Mi hijo (a) tiene permiso de caminar hasta lacasa *

YES/Si

NO/No

Home address/Domicilio *

My child can be picked up between 5:25-5:40 by the following person (different from the parent listed below)/Mi hijo (a) puede ser recogido entre las 5:25 y las 5:40 por las siguientes personas *

The phone number of the person who has permission to pick up your child/Tel *

Name of 2nd person who has permission to pick up your child

Phone Number of the 2nd person

BOOST reserves the right to dismiss your child from the program if the following statements are not followed/El Programma BOOST se reserva el derecho de despedir a su hijo (a) del programa de no seguir las siguientes instrucciones *

I understand that my child will be expected to behave according to the same rules as during the school day./Entiendo que se espera que mi hijo se comporte en conformidad a las mismas reglas que durante el dia escolar.

I understand that my child should attend at least 3 days a week (Monday, Wednesday and Thursday)./Entiendo que mi hijo (a) debe asistir por lo menos tres dias a la semana (Lunas, Miercoles, Jueves)

I understand that my child should not be picked up prior to 5:25 pm, unless arrangements have been made with the site coordinator./Entiendo que mi mijo no debe ser recogido antes de las 5:25 pm, a menos que se hayan hechos los arreglos necesarios con el coordinator del programa.

I understand that my child must be picked up no later than 5:40pm./Entiendo que mi hijo (a) no debe ser recogido depues de las 5:40pm.

Required

I allow BOOST to use photographic images of my child for program purposes/Le concedo permiso a BOOST para que tome foto con el proposito de ser usado especificamente para el programa. *

Yes/Si

NO/No

Parent/Guardian Name/Nombre del Padre/Guardian *

Parent phone number/Num. De Tel *

Parent/Guardian Initials/Firma del Padre/Guardian *

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