Summer School Registration Form

The deadline for Summer School registration is April 28th, 2017.

Please Note:

Use the tab key to easily navigate from field to field.

The asterisk (*) indicates a required field

General Info

General Info
calendar

Parent

Parent and Guardian information: (a minimum of one is required) *
 First NameLast NamePrimary PhoneSecondary PhoneEmail
1
2
3

Emergency Contact Info (OTHER THAN PARENT)

Please provide AT LEAST TWO emergency contacts that are not parents or guardians *
 Full NameRelationshipPrimary PhoneSecondary Phone
1
2
3
4

Medication Questions

The Foundation for Blind Children permits administration of either prescription or non prescription medications to enrolled students of the Summer School Program by the school nurse or a designated staff member.  In order to ensure the safety of all students, medications must be provided in the original pharmacy container with a pharmacy label clearly marked with your child’s name, date of birth, medication name and dose and how it is administered.   Medications must be current (cannot be expired) and the medication needs to be accompanied by a physician’s order. Written authorization signed by the student's parent/guardian must be provided as well. 
 
If you have current orders on file with FBC from the 2015-16 school year, you do not need to get new medical orders unless the orders have changed.
 
Thank You. 
My child has seizures:(If yes, you will receive a seizure action plan by mail to complete for the nurse prior to the start of program.) *

Program Location and Payment Information