St. Paul Baptist Church - Enrollment Application

SCHOLAR ENROLLMENT FORM

Please complete the enrollment application below and submit the completed application through the "Submit" button at the end of the form. If you are applying for multiple children, please complete an application for each child (although you only have to fill out the Family and Emergency Contact Information (Section B) once.

As an alternative to completing the application online, you can download a PDF of the application through the button below and email the completed form to us at freedomschool@stpaullive.org. Once again, if you are applying for multiple children, please complete an application for each child.

2024-Scholar-Application.pdf

Today's Date

SECTION A. SCHOLAR'S INFORMATION

Last Name

First Name

Date of birth

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

EMERGENCY CONTACT INFORMATION

Contact Person's Last Name

First Name

Is this person authorized to pick up the child(ren) you enrolled in the program??

Yes

Home Phone Number

Mobile Phone Number

Work Phone Number

Alternate #1 Last Name

First Name

Alternate #1 Mobile Phone Number

Alternate #1 Email

Alternate #2 Last Name

First Name

Alternate #2 Mobile Phone Number

Alternate #2 Email

Parent/Other Adult Caregiver Consent: In case of emergency, I give permission for any of the above individuals to be contacted and my child(ren) may be released to any of them.

Date

Parent/Guardian Consent: I understand that the organization that is enrolling my child(ren) 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.

Date Input

* Fields with an asterisk (*) are required.

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.

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SCHOLAR ENROLLMENT FORM

SECTION A. SCHOLAR'S INFORMATION

SECTION B: FAMILY INFORMATION

EMERGENCY CONTACT INFORMATION

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Service Time

Contact Info

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