IRVINGTON EXTENDED DAY

1320 NE Brazee * Portland, OR 97212 * (503) 287-9751* iedprogram2@gmail.com

Intake form for

BEFORE AND AFTER SCHOOL 2017-2018

 

Child’s name_________________________________ Date of birth__________ Sex__________

Address_____________________________________ Zip code_______________

Home Phone ______________________ Estimated entry date______________ Grade fall 2017__________

Custodial parent

Name_________________________________________ Relationship to child________________________

Work phone number________________________________

E-mail address_____________________________________(please print clearly)

Would you like to be contacted if there is an opening during the school year?

Yes_______ No________

Please circle the days your child will need to attend:

Before school only M T W TH F                             (MINIMUM OF THREE DAYS)

After School only M T W TH F                              (MINIMUM OF THREE DAYS)

Before and After                         M T W TH F                              (MINIMUM OF THREE DAYS)

Late Open Wednesdays             Y/N

___________________________________ ______________

Signature                                                  Date

**I will inform IED of any changes in this information**

For more information, please visit our website. www.iedprogram.org