B/A school application — Irvington Extended Day Program Irvington Extended Day Program

B/A school application

IRVINGTON EXTENDED DAY

1320 NE Brazee * Portland, OR 97212 * (503) 971-379-0331 iedprogram2@gmail.com

Intake form for

BEFORE AND AFTER SCHOOL  

Child’s name_________________________________ Date of birth__________ Sex__________

Address_____________________________________ Zip code_______________

Home Phone ______________________ Estimated entry date______________ Grade fall 20__________

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)

___________________________________ ______________

Signature                                                  Date

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

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