Vernonia Village Youth and Family Enrichment Program

Student First Name *

Student Last Name *

My student has an IEP, 504 or other medical needs *YesNo

If yes, please explain those needs:

Classroom Teacher *

Are there any academic areas you would like us to focus on with your student? *

What does your child love? What makes them "light up?" *

Is there anything else we should know about your child?0 / 180

Is busing needed? *YesNo

Address for bus drop off (within Vernonia School District)

Parent/Guardian 1 Full Name *

Parent/Guardian 1 Phone Number *

Parent/Guardian 1 Email Address *

Parent/Guardian 2 Full Name

Parent/Guardian 2 Phone Number

Parent/Guardian 2 Email Address

Street Address *

Apartment, suite, etc

City *

State *

ZIP / Postal Code *

Country

Person(s) Other than Parent/Guardian listed above who has permission to pick up student:Students WILL NOT be released to anyone who is NOT listed on this form.

Full Name

Phone Number

Relationship to Student

Photography/Videography Consent: I understand that my child may be photographed or on video as a part of this program. I give permission for such photos and videos to be used for promotional purposes by Vernonia School District and Camp Cedar Ridge. *YesNo

Join us for After-School Camp

For Grades K-5
Games, Arts and Crafts, Creative Arts, Academic Enrichment

No charge for students enrolled in Vernonia School District*
Transportation also provided for VSD students

*Funding for Vernonia School District students comes from the 21st Century Community Learning Centers grant recently awarded to Vernonia School District.

Register Your Student Now:

Join us for After-School Camp

For Grades K-5 Games, Arts and Crafts, Creative Arts, Academic Enrichment

No charge for students enrolled in Vernonia School District* Transportation also provided for VSD students

*Funding for Vernonia School District students comes from the 21st Century Community Learning Centers grant recently awarded to Vernonia School District.

Register Your Student Now:

For Grades K-5
Games, Arts and Crafts, Creative Arts, Academic Enrichment

No charge for students enrolled in Vernonia School District*
Transportation also provided for VSD students