English Whitworth IntranetEnglishLiteracy Center Application Literacy Center Application Please enter/select the following: Semester. Semester Fall/Spring Elementary (Entering Grades 1 - 6) Summer: Elementary (Completing Grades K - 5) Summer: Secondary (Completing Grades 6 - 12) Please enter/select the following: Preferred Session. Preferred Session Please enter/select the following: If your preferred session is full, are you able to attend an alternate session?. If your preferred session is full, are you able to attend an alternate session? No Yes Student Information Please enter/select the following: First Name. First Name Please enter/select the following: Last Name. Last Name Preferred Name/Nickname Please enter/select the following: Date of Birth (MM/DD/YYYY). Date of Birth (MM/DD/YYYY) Family Information Please enter/select the following: Parent/Guardian #1's First Name. Parent/Guardian #1's First Name Please enter/select the following: Parent/Guardian #1's Last Name. Parent/Guardian #1's Last Name Parent/Guardian #2's First Name Parent/Guardian #2's Last Name Please enter/select the following: Street Address. Street Address Please enter/select the following: City. City Please enter/select the following: State. State Please Select AA (military) AB (Canada) AE (military) AK AL AP (military) AR AS AZ BC (Canada) CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MB (Canada) MD ME MH MI MN MO MS MT NB (Canada) NC ND NE NH NJ NL (Canada) NM NS (Canada) NT (Canada) NU (Canada) NV NY MP OH OK ON (Canada) OR Other PA PE (Canada) PR PW QC (Canada) RI SC SD SK (Canada) TN TX UT VI VT VA WA WI WV WY YT (Canada) Please enter/select the following: ZIP/Postal Code. ZIP/Postal Code Please enter/select the following: Phone Number. Phone Number Please list the best number for contact during Literacy Center hours. Please enter/select the following: Alternate Phone Number. Alternate Phone Number Please enter/select the following: Email Address. Please enter the e-mail address in the form of me@you.com Email Address This email will be used for all communication related to program acceptance, tuition payment, and program updates School Information Please list information from the most recent school year. Please enter/select the following: What school did/does your child attend?. What school did/does your child attend? Please enter/select the following: What is/was your child's grade or program placement? . What is/was your child's grade or program placement? Please enter/select the following: Who is your Preferred Teacher Contact at your child's school or program?. Who is your Preferred Teacher Contact at your child's school or program? Please enter the e-mail address in the form of me@you.com Preferred Teacher Contact Email Address Do you give permission to discuss your child's academic needs with the teacher listed above? . Do you give permission to discuss your child's academic needs with the teacher listed above? No Yes Medical Information By initialing below*, I hereby grant permission for the staff of the Whitworth Literacy Center contact medical personnel to obtain emergency medical care if warranted. Please enter/select the following: Parent/Guardian's Initials. Parent/Guardian's Initials Please enter/select the following: Preferred Doctor/Medical Practice. Preferred Doctor/Medical Practice Please enter/select the following: Doctor/Medical Practice's Phone Number. Doctor/Medical Practice's Phone Number Please list any allergies, special medical and/or dietary needs: Please indicate any medications that your child is taking. *We ask that all medicine be given at home before or after coming to school. Emergency Contacts Your child will be released only to the custodial parent or legal guardian and the persons listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident, or emergency, if for some reason the custodial parent or legal guardian cannot be reached: Please enter/select the following: Emergency Contact #1's Name. Emergency Contact #1's Name Please enter/select the following: Emergency Contact #1's Relation to Child. Emergency Contact #1's Relation to Child Please enter/select the following: Emergency Contact #1's Phone Number. Emergency Contact #1's Phone Number Please list the best number for contact during Literacy Center hours. Emergency Contact #2's Name Emergency Contact #2's Relation to Child Please enter/select the following: Emergency Contact #2's Phone Number. Emergency Contact #2's Phone Number Please list the best number for contact during Literacy Center hours. Helpful Information About Your Child Please enter/select the following: What, if any, special services such as individualized education plan (IEP), counseling, speech therapy, occupational therapy or physical therapy during the school year?. What, if any, special services such as individualized education plan (IEP), counseling, speech therapy, occupational therapy or physical therapy during the school year? Please indicate any disabilities your child has Please indicate any languages other than English that your child speaks and their proficiency in listed languages Goals What are your goals for your child in the areas listed below? Literacy Math (Summer Only) Please enter/select the following: Would you like to apply for a partial scholarship for your child to attend the Literacy Center?. Would you like to apply for a partial scholarship for your child to attend the Literacy Center? Due to generous community partners, the Whitworth Secondary Literacy Center is able to offer partial scholarships to participants with financial need. A request for scholarship does not influence your acceptance into this program. No Yes Confirmation Please enter/select the following: By signing your full name below, you verify that all information on this application form is complete and accurate. By signing your full name below, you verify that all information on this application form is complete and accurate. SUBMITTING Submit