The Brooklyn Brownstone School
After school Flex Installment Plan

Child's Information

Child #1 First & Last Name

Child # 1 Birthday

Jour

Mois

Année

Child # 1 Grade

Child #1 Classroom

Child #1 Teacher's Name

Child #1 Diet

Does your child have any allergies?

YES

If Child #1 is allergic, what are they allergic to? Do these allergies restrict any activities? Do they carry an Epipen or inhaler?

Does your child require any one to one, IEP, or 504 accommodations during the school day?

Child # 1 Fears?

Child # 1 Likes and Dislikes?

Child # 1 Special Words and Meanings:

Are you enrolling another child in the program?

Guardian # 1 First name

Guardian # 1 Last name

Guardian # 1 Primary Email

Guardian # 1 Primary Phone

Guardian # 2 First Name

Guardian # 2 Last Name

Guardian #2 Primary Email

Guardian # 2 Primary Phone

List Any Non-Authorized Adults