1320 NE Brazee * Portland, OR 97212 * (503) 287-9751*

Intake form for


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:

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

___________________________________ ______________

Signature                                                  Date

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

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