Application

B/A Intake form

January 13, 2015 -

IRVINGTON EXTENDED DAY 1320 NE Brazee * Portland, OR 97212 * (503) 287-9751* 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… [read more]