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PROGRAM YOU ARE INTERESTED IN:

Oakland Freedom School (ages 5-13): TBA, 2012
Camp Akili (ages 14-17): TBA 2012

East Site or West Site *For Oakland Freedom School

West (Mount Zion Missionary Baptist Church (1203 Willow St. @ 12th Street)
East (Ile Omode School (8924 Holly Street)

Name

FirstLast

Middle Name

Gender

Age

Date of Birth

2011-2012 Grade Level

Mother's Name

FirstLast

Father's Name

FirstLast

Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Home Phone

Daytime Phone

Cell Phone

Email

Does your child live with

Single Parent
Both Parents

Does your child have Siblings?

Yes
No

If YES, please list

Emergency Contact

FirstLast

Relationship

Phone

Family Physician

Hospital/Medical Group

Hospital Phone

Child's Medical Number

Is your child on medication?

Yes
No

If YES, please list

Does your child have present or reoccurring health issues, special dietary needs or allergies?

Yes
No

In case of emergency, and parent or doctor cannot be reached, what action do you wish to be taken?

Special Needs Information

Does your child have any special needs (behavioral, emotional, relationships) of which we should be aware?

Your son/daughter needs support with

I, parent/guardian of, give permission for my son/daughter to participate in Leadership Excellence (LE) activities. I give permission for media release with the understanding that any photos, articles, student work, video footage, etc from my son/daughter may be used for promotional materials. I understand that if my son/daughter refuses to participate respectfully, it could result in their removal from the LE program. I understand that LE staff and volunteers will take the utmost care of my child, and in the unforeseen event of lost or damaged property, or unavoidable injury to my child, I will not hold LE or its staff/volunteers liable. I understand the goals of Leadership Excellence and gladly support my child, and the LE facilitators, in achieving these goals. Forward!*

I consent

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