DragonHeat Summer Application Form


                         

                        

Name: 


A red asterisk (*) indicates required questions.

  1. Student Name*


  1. Address*


  1. City*


  1. State*


  1. Zip*


  1. Home Phone -- Example 999-999-9999. If no home phone enter n/a for not applicable.*


  1. Date of Birth -- Example mm/dd/yyyy*


  1. Student ID#*


  1. Grade 2013-2014*
    09
    10
    11


  1. Present School*


  1. Parent Name (Please include Title, First and Last name -- Example: Mr. Patrick Johnson)*


  1. Parent's Home Phone -- Example 999-999-9999. If no home phone enter n/a for not applicable.*


  1. Parent's Cell Phone -- Example 999-999-9999. If no cell phone enter n/a for not applicable.*


  1. Parent's Work Phone -- Example 999-999-9999. If no work phone enter n/a for not applicable.*


  1. Emergency Contact Name (Please include Title, First and Last name -- Example: Mr. Patrick Johnson)


  1. Emergency Contact Phone -- Example 999-999-9999


  1. Choose the method of transportation.
    Walking
    Parent Pick-up
    Bus


  1. If you choose Bus be sure to check one depot stop below if beyond the 2 mile radius.
    Westood Heights Elementary Pick-up 7:22 a.m. Drop-off 12:24 p.m.
    Stephen Foster Elementary Pick-up 7:27 a.m. Drop-off 12:18 p.m.
    Croissant Park Elementary Pick-up 7:37 a.m. Drop-off 12:08 p.m.
    Walter C. Young Middle Pick-up 5:45 a.m. Drop-off 1:40 p.m.
    New Renaissance Middle Pick-up 6:10 a.m. Drop-off 1:10 p.m.
    Hollywood Central Elem. Pick-up 7:00 a.m. Drop-off 12:45 p.m.


  1. Family Doctor (Please provide the name of your family doctor)


  1. Phone Number of your family doctor -- Example 999-999-9999


  1. Please list any health concerns or allergies your child may have





Mrs. Brim
Media Specialist
Year
NORTH LAUDERDALE, FL