Capitol Educational Support Inc.

Presents
TAKOMA EC/SUMMER SCHOOL
REGISTRATION FORM

Student Name:
Siblings Attending:
Address:
City:
Parents/Legal Guardian Name:
Parent/Legal Guardian Email Address:
Phone:

(h)

Student Age:

(w)
Student Grade:

(c)
Student DOB:

Current School Attending:

Emergency Contact Person:
Emergency Contact Phone:

(c)

Sessions: Check ALL Weeks Child Attending

Week 1 (June 27 July 1):
Week 2 (*July 5 July 8):
Week 1 (July 11 July 15):
Week 1 (July 18 July 22):
Week 1 (July 25 July 29):

__________
__________
__________
__________
__________

*July 4th HOLIDAY NO CAMP

Please check here if you will be applying as TANF RECIPIENT ___________
You DO NOT have to be receiving TANF, however your income must be TANF Eligible
TANF Eligible students will receive priority
Non-TANF Students will also be accepted

Submission Dates
***REGISTRATION FORMS ARE DUE JUNE 17, 2016***
Registration forms may be faxed to (888) 395-0772, or sent via email to ces.dc20002@gmail.com.

Before and Aftercare REGISTRATION FORM (Continued)

Health/Medical Info
Does Your child have Health Insurance:

Yes:

No:

Health Insurance Company:

Health Insurance Company Phone #:
Policy Holder:

Policy #

Does the student have any Food Allergies or Medical/Health conditions?

Yes:

No:

If Yes, Please list or describe here:

Health Waiver
I/we, the undersigned, hereby certify that I/we are the parent or legal guardian of the Student. I/we further
certify that the Student is physically capable of participating in all activities. I/we agree to provide the
Student with the appropriate documentation on or before the first day of services, restricting the Student
from participating in specified activities. (Must be a signed letter from parent or a signed doctors certificate)
I/we hereby give permission for the staff of Capitol Educational Support Inc. to seek appropriate medical
treatment for the Student during the period of the Before and After Care and for the camper to receive
medical attention in the event of an accident, injury, disease or illness. I/we will be responsible for all costs of
medical attention provided.
Print Student Name:
Print Parent/Legal Guardian Name:
Signature Parent/Legal Guardian Name:
Date:

LATE POLICY: Three (3) consecutive late pick-ups will result in a one-day suspension from the
Program

Before and Aftercare REGISTRATION FORM (Continued)

TERMINATION BY THE PROGRAM: The Program may terminate your childs enrollment immediately for
any of the following reasons:
a. In the judgment of CES Takoma Site Director and staff, the childs behavior threatens the
physical or mental well-being of other children in the Program.
______ Initials
b. The family has more than two suspensions for tardiness.
_______ Initials
Written warnings/incident reports will be provided to parents, school staff as they occur.

CHILD RELEASE AUTHORIZATION FORM

Childs Name: _______________________________________________ DOB: ________________

The CES Afterschool Program is authorized to release my child to the individuals listed below. I
understand that each authorized person must be at least 16 years old and that my child will not be
permitted to leave the Program with anyone not listed below.
Signature:
_______________________________________________________________ Date: _______________
AUTHORIZED PERSONS FOR PICKUP (INCLUDING YOURSELF)
Name: _______________________________________ Relationship to Child: ___________________
Address: ____________________________________ City/State/Zip: ___________________________
Home No.: __________________ Work No.: _________________ Cell No: ___________________
Name: _______________________________________ Relationship to Child: ___________________
Address: ____________________________________ City/State/Zip: ___________________________
Home No.: __________________ Work No.: _________________ Cell No: ___________________
Name: _______________________________________ Relationship to Child: ___________________
Address: ____________________________________ City/State/Zip: ___________________________
Home No.: __________________ Work No.: _________________ Cell No: ___________________
If you have questions, please contact:
Mia Stewart
Dir: 202-957-1331

Capitol Educational Support, Inc.

820 H St., NE
Washington, DC 20002

Takoma Education Campus

7010 Piney Branch Rd., NW
Washington, DC 20012