English Whitworth IntranetEnglishLiteracy Center Application Literacy Center Application Semester Fall/Spring Elementary (Entering Grades 1 - 6)Summer: Elementary (Completing Grades K - 5)Summer: Secondary (Completing Grades 6 - 12) Preferred Session If your preferred session is full, are you able to attend an alternate session? NoYes Student Information First Name Last Name Preferred Name/Nickname Date of Birth (MM/DD/YYYY) Family Information Parent/Guardian #1's First Name Parent/Guardian #1's Last Name Parent/Guardian #2's First Name Parent/Guardian #2's Last Name Street Address City 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) ZIP/Postal Code Phone Number Please list the best number for contact during Literacy Center hours. Alternate Phone Number 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. What school did/does your child attend? What is/was your child's grade or program placement? Who is your Preferred Teacher Contact at your child's school or program? Preferred Teacher Contact Email Address Do you give permission to discuss your child's academic needs with the teacher listed above? NoYes 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. Parent/Guardian's Initials Preferred Doctor/Medical Practice 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: Emergency Contact #1's Name Emergency Contact #1's Relation to Child 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 Emergency Contact #2's Phone Number Please list the best number for contact during Literacy Center hours. Helpful Information About Your Child 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) 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. NoYes Confirmation By signing your full name below, you verify that all information on this application form is complete and accurate. SUBMITTING Submit