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Youth Arts and Academic Enrichment After Care Summer Program 2019
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Student #1 First Name
Your answer
Student #1 Last Name
Your answer
Student #1 Gender
Male
Female
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Student #1 Birthday
MM
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DD
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Student #1 Grade
2018-2019 School Year
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TK
K
1
2
3
4
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6
7
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Student #1 Current School
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Camarillo Heights STEM Academy
Dos Caminos School
Pleasant Valley School of Engineering and Arts
La Mariposa School
Las Posas School
Los Primeros School of Science and Arts
Rancho Rosal School
Santa Rosa Technology Magnet School
Tierra Linda School
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Student #1: Are there any special conditions which we need to be aware of when providing care for your child?
If Yes, Click Other and please explain
No
Other:
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Student #1: Does your child take medication daily or on an as needed basis (i.e. inhaler for asthma, Benadryl for allergies, etc)?
If Yes, Click Other and please explain
No
Other:
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#1 Will you be enrolling another student in the Youth Arts and Academic Enrichment After Care Summer Program?
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Yes
No
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