Galileo School of Math and Science Summer School Registration www.d11.org/galileo 719-328-2200 PLEASE PRINT OR TYPE ALL INFORMATION School your child is currently attending: _____________________________________________ Student Name: ________________________ Current Grade: ______ Birth Date: _____________ Parent/Guardian: _________________________________________________________________ Address: ___________________________________ City: ________________________________ State: ________ ZIP: ___________ Home Phone: _______________________________________ Work Phone: ________________________ Cell/Pager: __________________________________ Emergency Contact Name (list anyone besides parent that is allowed to pick up your child.) Photo ID will be required upon pick up:_______________________________________________ Name: Relationship:_______________________________________________________________ Phone: _______________________________ Additional Phone:___________________________ Application Deadline - May 22*** Please return application to: Galileo School of Math and Science 1600 North Union Blvd Colorado Springs, CO 80909 You may also download the application from the website and email the form to brisbsj@d11.org. ***Applications will be accepted until the May 22nd deadline. Any applications received after the deadline will be wait-listed for possible slots available on June 1st. There are a limited amount of spaces available. Spaces will be given on a first come, first serve basis. HEALTH INFORMATION Is your child currently taking medication
Yes
No
Will medication be given at school?
Yes
No
Please name the medication: ____________________________________________________ Please circle if your child has experienced the following: Life threatening allergies Seizure disorders Heart condition Severe bee sting allergy Asthma Diabetes Bone or joint disease Hearing impairment Severe vision problem Please comment on any problems circled above: ___________________________________ Other health problems (please describe): __________________________________________ Parent/Guardian Signature ____________________________________ Date ______________