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Big Ideas Summer 2022 Application
A separate application MUST be completed for each child registered into the program.
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STUDENT INFORMATION
Please ensure all information entered is accurate and current.
Student Name
*
First
Middle
Last
A separate application must be completed for each student.
School Site
*
Please select
Lakeview Elementary
Barbara Hawkins Elementary
Lorah Park Elementary
Crestview Elementary
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Student ID Number
*
Your student's Identification Number can be found on his/her report card. Please also ask your student this is their school lunch number.
(If you do not know your child's ID#, please type 999-9999)
Current 2021-22 school year grade level
*
K
1
2
3
4
Summer 2022 DO NOT accept current 2021-22 5th grade students into the summer program.
Does your student receive free or reduced lunch?
*
Yes
No
Transportation Mode:
*
Walk
Bus
Pick-upp
Other
Student Race / National Origin
*
Please select
American Indian or Alaskan
Asian
Black
Multiracial
Other
Pacific Islander
White
Child Ethnicity
*
Please select
Asian American
Black /African American(non-Hispanic)
Haitian Creole
Hispanic / Latino origin
Native American
White / European American
Is the Student Proficient in English?
*
Yes
No
Is this student Hispanic or Latino?
*
Yes, Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.)
No, not Hispanic or Latino
Unknown
Primary Language: spoken in your home
*
English
Spanish
Haitian Creole/ French
Other
Check all that applies
Does child have health insurance? (ex., private insurance, KidCare, Medicaid) 0 Yes 0 No
(If not, we may be able to help you find affordable coverage – call 211 or visit www.thechildrenstrust.org/parents/health-connect/insurance.)
*
Yes
No
Student Home Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Education Program:
Select Education Programs
*
Homeless
ELL/LEP
Special Education /ESE
Gifted & Talented
Bilingual
N/A
select all that applies to your student.
Does the student have a documented disability?
*
Yes
No
If YES, you MUST provide supporting documentation and complete the next three questions.
If No, Please proceed to Parent/Guardian Information.
If yes, do you have
an Individualized Education Plan (IEP) from the school system
a Section 504 Plan
a medical diagnosis from a doctor
Other
Check all that applies
Upload Supporting Documentation
If you answered yes to the above, how would you best classify the type(s)?
Autism Spectrum Disorders
Chronic Medical Condition
Emotional and/or Behavioral Disorder
Hearing Impairment (or deaf)
Intellectual Disability (or mental retardation)
Learning Disability
Physical Disability
Speech/Language Impairment
Visual Impairment (or blind)
English Language Learner
Other
Check all that applies
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