Scholar Enrollment Form

Child's Information

First Name

Middle Name

Last Name

Birthdate

mm/dd/yyyy

Gender Identity

Preferred Pronoun

Freedom School Information

Freedom School Name (format: State - Sponsor - Site)

Begin typing the name of your state postal abbreviation, sponsor, or site to filter results

Child's Level

Child's Home Address

Street

City

State

Zip Code

Child's School Information (2023-2024)

Type of school that your child attended

Child's grade level

School Name

School City

School State

What is your child’s reading proficiency level?

Has your child ever qualified for an Individual Educational Plan (IEP) or 504 plan?

Does your child receive or qualify for free/reduced price lunch during the school year?

Additional Information

Has your child ever attended a CDF FS Summer or After-School program before?

How many years has your child participated in the CDF Freedom Schools program?

Please list any languages your child speaks at home

Is your child an English Language Learner? (English is not their first language)

Does your child have health insurance?

What is your child's health insurance carrier?

Does your child have any allergies or health conditions of which we should be made aware? If yes, what?

What are some strategies our team can use to best support your child's learning throughout the program? (ex: needs additional reading help, prefers small groups, etc.)

Is there anything else that you would like to share about your child?

Child's t-shirt size

Parent/Guardian Information - The Adult Completing This Form

First Name

Last Name

Relationship to Child

Relationship to Child OTHER

Is this person the child's legal guardian?

Gender Identity

Preferred Pronoun

Home Phone

Mobile Phone

Work Phone

Email

Alternate Email

Would you like to opt-in to receive general email communications from CDF?

YesNo

Child's Household Information

How many people live in the child's household?

How many children aged 6-18 live in the child's household?

How many children aged 5 and under live in the child's household?

Other Adults

Emergency Contact Information

First Name

Middle Name

Last Name

Is this person authorized to pick up the child enrolled in the program?

Home Phone

Mobile Phone

Work Phone

Email

What other adult is authorized pickup the child?

First Name

Last Name

Relationship

Mobile Phone

Signature Page

I understand that the organization that is enrolling my child in the CDF Freedom Schools® program is in partnership with the Children’s Defense Fund to offer this program. This personal information will be kept private and confidential and will only be shared with CDF to collect demographic information on children served and to report out this information in aggregate form.

In case of an emergency and I cannot be reached, I give permission to contact the individuals I have authorized on the previous page, and to release my child to them.

If you elected to receive CDF emails, note that we may use the information you provide to us on this form to communicate further with you (including to send you promotional materials about the Children’s Defense Fund). For more information about how we collect, use, and share information, please see the Privacy Policy on our website www.childrensdefense.org.

Signature