Oakland Freedom School

Registration Form Student Information Full Name: Last School: Current School Parents: Mothers Name Address: E-mail Address: Mom Cell ( Health Information
Any Health Conditions? Any Medications?

First Grade in Fall 12 Age

M.I. Birthdate:

Gender Month/Date/Year Guardian

Fathers Name City, Zip: ) Dad Cell (

Family Physician: Physician Phone #: Preferred Hospital: Provider # Emergency Contact Information Last First M.I. Apartment/Unit # State ZIP Code

Any Allergies?
Insurance provider?

Full Name: Address: Street Address City Primary Phone: (

) Alternate Phone: ( ) Permission to Travel & Treat (check boxes to acknowledge statement)

I, ____________________________ give my child __________________________ permission to participate in all Oakland Freedom School (OFS) field trips including walking trips to parks, libraries, and local businesses. I give OFS staff permission to transport my child in cars, charter and public AC Transit busses, BART trains and on foot to these field trips. I authorize OFS to provide basic first aid to my child for minor surface injuries. I further authorize OFS staff to contact an ambulance or transport my child to the nearest hospital if they sustain any major injuries or become seriously ill. I understand that OFS staff CANNOT provide my child with Aspirin, Tylenol, or any other medication. I have initialed the above statements indicating that I acknowledge, agree to and consent to these terms. ______________________________________ Parent Name
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_____________________________________ _______________ Parent Signature Date Program Information

Program site: Frick Middle School 2845 64 St Oakland. Start time: 8:30am End time: 3:00pm Site Coordinator cell (510) 846-8454 Program Director cell (510) 846-5402 Lincoln Main Office # (510) 531-3111 x0 To Register (check box to indicate registration status) nd Early Registration ($200 early registration due by May 2 or late registration fee will apply) nd Late Registration ($225 late registration due by June 2 or your childs slot may be opened to wait list) Request Scholarship (Scholarship form must be completed and submitted with registration) Payment may be made by check or online via PayPal at www.leadershipexcellence.org Check made payable to Lincoln Child Center Send Check to: 4368 Lincoln Avenue, Oakland, CA 94602