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ZOE LIVE CREATIVE ARTS ACADEMY

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Creative Lab After-School Program

Registration Form

Student Information

Student First Name*

Student Middle Name

Student Last Name*

Birth Date*

School*

Student Grade*

Home Address*

City*

State*

Zip Code*

Student Lives With*

Both Parents

Mother

Father

Aunt/Uncle

Sister/Brother

Grandparent

Guardian

Other

Race*

American Indian/Alaska Native

Asian

Black/African-American

Native Hawaiian/Pacific Islander

White

Multiracial

Other

Ethnicity*

Not Applicable

Hispanic

Haitian

Other

Primary Language Spoken*

T-Shirt Size*

Other Student Information

Tutoring Days*

Monday

Tuesday

Wednesday

Thursday

Friday

Please select the days you would like for your student to receive tutoring/homework assistance.

Piano Lab Registration*

Yes

No

Are you also registering your child for Piano Lab? All piano lab sessions occur on Wednesdays.

Academic and Music Needs*

Below grade level for age

Has a record of poor school attendance/truancy

Needs tutoring for Reading

Needs tutoring for Math

Has taken music lessons

Other

Please check all that apply.

Allergies/Medical Condition*

Yes

No

Does the student have any allergies or medical conditions?

Allergies/Medical Condition Details

Please enter any allergies or medical conditions we should be aware of.

Regular Medication*

Yes

No

Does your child take any medication(s)?

Current Medication List

Please enter any medications your child takes regularly that we should be aware of.

Special Needs/Disability*

Yes

No

Does your child have a disability or require special physical or educational accommodations?

Help Child Receives*

Behavioral therapy or services

Counseling for emotional concerns

Daily medication (not including vitamins)

Occupational Therapy (OT)

Physical Therapy (PT)

Special education services in school

Speech/language therapy

None of the above

Ways Student Communicates*

Speaks and is easily understood

Speaks but is difficult to understand

Uses communication devices like pictures or a board

Uses gestures or expressions like pointing, pulling, smiling, frowning or blinking

Uses sign language

Uses sounds that are not words like laughing, crying or grunting

Free/Reduced Lunch*

Yes

No

Does your child receive free/reduced lunch?

Parent/Guardian Information

Parent/Guardian First Name*

Parent/Guardian Last Name*

Relationship to Student*

Country/Region*

Address*

City*

Zip / Postal code*

Email*

Phone Number*

Highest Level of Education*

Household Information

Household Size*

Please enter the number of individuals living in your household.

Annual Household Income*

Languages Spoken at Home*

English

Spanish

Creole

Emergency Contacts

Emergency Contact 1

Emergency Contact 1 First Name*

Emergency Contact 1 Last Name Name*

Relationship to Student*

Phone Number - Cell*

Phone Number - Home

Phone Number - Work

Emergency Contact 2

Emergency Contact 2 First Name*

Emergency Contact 2 Last Name*

Relationship to Student*

Phone Number - Cell*

Phone Number - Home

Phone Number - Work

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