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After School Enrichment Form
After School Enrichment Details
*
Yes
No
Please populate this form so your child is set up with The FitKid Academy
Student Information
Student First Name
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Student Last Name
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Gender
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Boy
Girl
Birth Date
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Does the Student have a mobile number?
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Yes
No
Mobile Phone
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Street Address
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City
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State
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Zip Code
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Doctor's First Name
Doctor's Last Name
Doctor's Phone
Parent/Guardian Information
First Name
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Last Name
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Email Address
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Mobile Phone
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Home Phone
Work Phone
Primary Phone
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Please select an option
Mobile
Home
Work
Is your address the same as the Student's?
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Yes
No
Street Address
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City
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State
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Zip Code
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Enter another Parent/Guardian information?
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Yes
No
First Name
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Last Name
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Email Address
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Mobile Phone
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Home Phone
Work Phone
Primary Phone
*
Please select an option
Mobile
Home
Work
Is your address the same as the Student's?
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Yes
No
Street Address
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City
*
State
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Zip Code
*
Other Information
Would your child like to be in a class with a friend?
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Yes
No
Please list each name and age of the friend(s)
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Is your child immunized?
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Yes
No
Does your child have any allergies?
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Yes
No
Please list any food or drug allergies
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Does your child have any medical conditions?
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Yes
No
Please list any medical conditions
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Does your child require any medication?
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Yes
No
Please list any medications needed
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Do you authorize us to administer the medications listed above?
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Yes
No
Please list the people authorized to pick up your child
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Does your child have any siblings?
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Yes
No
Please list their name(s) & age(s)
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Does your child play sports?
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Yes
No
Please list their sports
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Additional Comments
Emergency Contact
Other than Parent/Guardian
First Name
*
Last Name
*
Email Address
*
Mobile Phone
*
Home Phone
Work Phone
Primary Phone
*
Please select an option
Mobile
Home
Work
Street Address
*
City
*
State
*
Zip Code
*
Submit Enrichment Program Information
Please do not fill in this field.