Literacy Center Application

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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? No
Yes

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

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? 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.

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. No
Yes

Confirmation

By signing your full name below, you verify that all information on this application form is complete and accurate.

Submit