Portsmouth Enrichment Programs

Student First Name: Student Last Name:

Grade: 6 7 8  Learning Center: Please Select One A2 A3 C1 C2 D1 D2 Home Room Teacher:

Which Enrichment Class: Please Select One Chinese Beginning Chinese Continuing Spanish Beginning Spanish Continuing

Does your child have any allergies? No Yes

     If your child has allergies, what to?

Does your child have any special concerns or learning needs we should be aware of? No Yes

     If yes, please explain?

Parent Name:

Home Phone:   Cell Phone:   Work Phone:

Email:

Parent Name:

Home Phone:   Cell Phone:   Work Phone:

Email:

Emergency Contact:

Home Phone:   Cell Phone:   Work Phone:

Emergency Contact:

Home Phone:   Cell Phone:   Work Phone:

For after school programs only:
I give permission for any of the following individuals to pick up my child at the end of class: (Useful for shared rides and carpooling etc.)

Name: Telephone:

Name: Telephone:

Name: Telephone:

Name: Telephone:

I want my child to take the late bus when it is available. I will check the bus schedule every week for updates/changes. The Tuesday and Thursday busses do not run every week.

In the event that After School Enrichment is cancelled, my child will;
Take the bus home
Be picked up by myself or others on my list
Other (please specify here):

I’d like to volunteer as a classroom assistant. Yes or No.

I understand and agree to the guidelines. (please check)

Parent/guardian _________________________________Date________________

Classes run for 22 weeks, beginning the week of October 19, 2009. The cost of tuition is $175. Additionally, you will be notified if there is a fee for classroom materials /books. Loaner Chinese Texts are available. Foreign Language Enrichment is not a fundraiser. The goal of the fee structure is to charge for real costs. A limited amount of financial aide is available. Class schedules will be sent home via backpack before classes begin.

A. Once you fill in the form correctly, please click the submit button. This will send the form to our data files and will present you with a page of your answers.

B. Please PRINT THAT PAGE (a copy for your records and a copy to send in with your check). Please send your check (payable to Portsmouth Enrichment Incorporated) and form to school via "backpack express" or mail to:

Cathleen Hickey
Portsmouth Middle School
125 Jepson Lane
Portsmouth, RI 02871

Thank you!