Application for Extended Learning Program MCCS 2022-2023 Extended Learning Program School Year:*2021 - 2022Section I - STUDENT INFORMATIONName: *Birth date (MM/DD/YYYY): *SexMFGradeK12345MDCPS Student ID Number: School currently attending: Home AddressStreet AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodeApt./Trailer #: Home Phone:Cell Phone:Emergency Phone:Date Section II PARENT INFORMATIONMother's NameFirstLastWork PhoneFather's NameFirstLastWork PhoneLegal Guardian NameFirstLastWork PhoneSection III MEDICAL INFORMATIONChild's doctor: Phone:*Address: Hospital / Clinic:May we contact another doctor if unable to call the child's doctor?*YesNo Do you authorize MCCS to provide emergency care at the closest hospital in case of emergency? *YesNo Does the child have any medical conditions that we should be aware of?*YesNo Does you child have any ALLERGIES we should be aware of?YesNo (If so, please describe the allergies)Please list the names of person(s) whom you give permission to pick up the child from the program or may contact in case of an emergency if you cannot be reached. (*MUST PRESENT ID) NameFirstLastRelationship:PhoneNameFirstLastRelationship:PhoneNameFirstLastRelationship:PhoneParent/Guardian’s Name (PLEASE PRINT) *Parent/Guardian’s Signature*Date*
