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World Explorers

PS 38 World Explorers Afterschool
Flex Installment Plan

Child #1 First & Last Name

Child # 1 Birthday

Month

Day

Year

Child # 1 Grade

Child #1 Classroom

Child #1 Teacher's Name

Child #1 Diet

Does your child have any allergies?*

YES

NO

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

We are here for you!

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