ESY 2019 Registration form
Student LAST name
Student FIRST name
Will your child attend ESY?
If yes, please complete the ESY registration form.
Parent Phone #
Emergency Phone #
AHSD25 has permission to photograph my child for educational purposes and media coverage.
Medical information: we will gather information from your child's school nurse.
Is there any additional health information you want to share?
Medication administration during ESY.
You are responsible for bringing medication and medical plan to Greenbrier School by June 10th.
If the parents/guardians cannot be contacted in case of serious injury or illness, I authorize the school to take emergency action as may be deemed necessary, including the transportation of the student to a hospital or medical center. As the parent/guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of the above named minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after reasonable effort is made to contact me.
Does your child need taxi transportation?
Please complete the following for transportation.
Monday - Thursday (EC program)
Monday - Friday (K-7 program)
other - list days below
Transportation Days - other
Arrival AND Dismissal
Pick up address:
Drop off address:
Send me a copy of my responses
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