YOUTH REGISTRATION

Welcome to the CDF Freedom Schools student enrollment site. The links on this site are for the exclusive use of families enrolling their children in the 2016-2017 CDF Freedom Schools programs on Hawaii (Big Island). Parents, please note that an individual registration form is required for each child.

If you experience difficulty registering your child for the program(s) on the Big Island, write to the CDF Freedom Schools' Hawaii-KOA Coordinator, Ms. Michelle Romo, at mromo@childrensdefense.org.
INSTRUCTIONS: Please complete one form for each child enrolled in the CDF Freedom Schools program.
All fields are REQUIRED, unless noted by an (*) ASTERISK.
Enrollment Date
Parent/Guardian's Name
Relationship to this child
Is this child living with you?
Y  N 
CHILD'S RESIDENT ADDRESS
Street
City
State
ZIP
CHILD'S DEMOGRAPHIC INFORMATION
Last Name
First Name
Middle Initial
Suffix
Preferred Name or Nickname
Date of Birth
Gender
Female  Male 
Primary Language
Race/Ethnicity
* Other Ethnicity
Does your child have any siblings?
Y  N  Unknown 
* If yes, how many?
Does this child have a sibling(s) who currently participates, or has participated in the Freedom Schools program?
Y  N  Unknown 
How did you find out about the Freedom Schools program?
CHILD'S ACADEMIC INFORMATION
* What other academic enrichment or extra-curricular activities does your child participate in during the summer or academic school year (e.g. organized sports, music, or dance lessons, academic tutoring, clubs or organizations)?
Does your child receive or qualify for free/reduced price lunch at school during the academic school year?
Yes  No  Unknown 
What type of school does your child attend?
What is the Name and Address of the school your child attends during the academic school year?
School Street Address
City
State
ZIP
What academic grade level was your child enrolled in during the most recent academic school year?
Has this child been in foster care at any point in his or her life?
Y  N  Unknown 
Does your child participate in any of the following educational programs?
Bilingual Education
Y  N  Unknown 
ESL/LEP
Y  N  Unknown 
Special Education
Y  N  Unknown 
Gifted and Talented
Y  N  Unknown 
* Other
Has a doctor, health professional, teacher, or school official ever informed you that your child has a learning disability?
Y  N  Unknown 
* If Yes, please explain:
Has your child ever repeated a grade?
Yes  No  Unknown 
Has your child attended a CDF Freedom Schools summer program before?
Yes  No  Unknown 
If yes, how many summers has your child participated?(NOT including the current summer)
What Integrated Reading Curriculum (IRC) level will your child be enrolled in this summer (use grade level from most recent academic school year)?
What is your child’s Reading Proficiency Level?
CONSENT
Parent Consent
Y  N  Unknown 
Media Consent
Y  N  Unknown 
TRANSPORTATION
How will your child travel to and from the program site each day?
 MEDICAL INFORMATION
Does this child have health insurance?
Yes  No  Unknown 
Primary Doctor
Telephone
Preferred Hospital
Hospital Location
If yes, please complete the information requested below:
Health Insurance Carrier
Name of Policy Holder
* Identification Number
* Group Number
* Please explain any special procedures that should be followed in the event of a medical emergency:
Has a doctor or health professional ever told you that this child has any of the following conditions?
Asthma
Yes  No  Unknown 
Hearing Problems
Yes  No  Unknown 
Vision Problems
Yes  No  Unknown 
Attention Deficit Disorder (ADD)
Yes  No  Unknown 
Attention Deficit Hyperactivity Disorder (ADHD)
Yes  No  Unknown 
Depression or anxiety problems
Yes  No  Unknown 
Behavior or conduct problems
Yes  No  Unknown 
Bone, joint or muscle problems
Yes  No  Unknown 
Diabetes
Yes  No  Unknown 
Autism
Yes  No  Unknown 
Obesity
Yes  No  Unknown 
Any development delay or physical impairment
Yes  No  Unknown 
* Please describe:
* Does your child have any known medical conditions or disabilities that do not appear in the list above? If so, please describe:
* Does your child have any dietary, allergenic, or exercise restrictions? If so, please describe:
Does your child currently need or use medication prescribed by a doctor?
Y  N  Unknown 
* If Yes, Please list the medication:
Is your child limited or prevented in any way from participating in moderate to strenuous physical activity?
Y  N  Unknown 
* If Yes, Please explain:
Has this child been to the doctor for any reason in the last 12 months?
Y  N  Unknown 
During the past 12 months, have you been told by a doctor or other health professional that your child had any of the following conditions?
Hay Fever
Yes  No  Unknown 
Any kind of food or digestive allergy
Yes  No  Unknown 
Eczema or any kind of skin allergy
Yes  No  Unknown 
Frequent or severe headaches(migraines)
Yes  No  Unknown 
Speech problems
Yes  No  Unknown 
Three or more ear infections
Yes  No  Unknown 
Other Condition
Yes  No  Unknown 
* Please List Other:
* Has your child been to the dentist in the last 12 months?
Y  N  Unknown 
* Has your child been to an optometrist within the past 12 months?
Y  N  Unknown 
* If there is anything else that you would like to share about your child, please indicate here.
 EMERGENCY CONTACT INFORMATION
* Emergency contact's first and last name:
Emergency contact's relationship to your child(ren):
* Primary Emergency Contact:
* Home Phone:
Email:
Please list any other persons (age 21 and older) who are authorized to pick up your child(ren). (1) Delete
May pick up - Name
May pick up - Relation
May pick up - Phone
Click here to add 'Please list any other persons (age 21 and older) who are authorized to pick up your child(ren).'