B/A Intake form
IRVINGTON EXTENDED DAY
1320 NE Brazee * Portland, OR 97212 * (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
