ECOLE BILINGUE DE BERKELEY STUDENT AND PARENT INFORMATION INCOMPLETE
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Collector: Student Inform...Forms 2015-16 (Email) Started: Wednesday, June 03, 2015 4:11:48 PM Last Modified: Wednesday, June 03, 2015 4:23:17 PM Time Spent: 00:11:28 First Name: Ann Last Name: Lefkovits Email: annlefko@gmail.com IP Address: 73.162.132.195
PAGE 2: ARE YOU NEW TO EB?
Q1: Will you be a new EB family next school year?
No
PAGE 3: CHANGED CONTACT INFORMATION
No changes
Q2: During the last school year, I have
PAGE 4: STUDENT 1 INFORMATION
Q3: Student 1 Last name
Lefkovits
First name
Marcus
Entering grade
4
Date of birth
05/07/2006
City of birth
Berkeley
State of birth
California
Country of birth
Alameda
Street address
1245 66th St
City
Emeryville
State
Ca
Zip
94608
Home Phone
415-710-4660
Q4: What is your child's ethnicity? Please select options below Ethnicit y
Multiracial American (People who identify with more than one ethnic race heritage and are US citizen or permanent resident of the United States)
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ECOLE BILINGUE DE BERKELEY STUDENT AND PARENT INFORMATION Q5: What are your child's nationalities?
US
Q6: Will you have another child enrolled at EB next year?
No
PAGE 5: STUDENT 2 INFORMATION
Q7: Student 2
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Q8: What is your child's ethnicity?
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Q9: What are your child's nationalities?
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Q10: Will you have another child enrolled at EB next year?
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PAGE 6: STUDENT 3 INFORMATION
Q11: Student 3
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Q12: What is your child's ethnicity?
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Q13: What are your child's nationalities?
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Q14: Will you have another child enrolled at EB next year?
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PAGE 7: STUDENT 4 INFORMATION
Q15: Student 4
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Q16: What is your child's ethnicity?
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Q17: What are your child's nationalities?
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ECOLE BILINGUE DE BERKELEY STUDENT AND PARENT INFORMATION PAGE 8: PARENT 1 / GUARDIAN 1 INFORMATION
Q18: CONTACT INFORMATION* Please note: "if different" below means if your address or phone is different from your student's address or phone. Last name Lefkovits First name
Ann
Birth country
USA
Cell Phone
415-710-4660
Annlefko@gmail.com
Q19: PROFESSIONAL INFORMATION Employer's name
Self
Position
Yoga teacher
Profession
Yoga
Q20: Does your employer offer a matching gift?
No
Q21: What is your ethnicity? Please select options below Ethnicity
Caucasian (European American)
Q22: What are your nationalities?
US
Q23: What language(s) do you speak at home?
English
Q24: Do you need to enter the information of another parent / guardian?
Yes
PAGE 9: PARENT 2 / GUARDIAN 2 INFORMATION
Q25: CONTACT INFORMATION* Please note: "if different" below means if your address or phone is different from your student's address or phone. Last name
Lefkovits
First name
Stephen
Birth country
USA
Cell Phone
4153121117
Steve.lefkovits@gmail.com
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ECOLE BILINGUE DE BERKELEY STUDENT AND PARENT INFORMATION Q26: PROFESSIONAL INFORMATION Employer's name
Self
Position
Owner
Profession
Multi family housing
Q27: Does your employer offer a matching gift?
No
Q28: What is your ethnicity? Please select options below Ethnicity
African American
Q29: What are your nationalities?
US
Q30: What language(s) do you speak at home?
English
Q31: Do you need to enter the information of another parent / guardian?
No
PAGE 10: GRANDPARENT'S INFORMATION SKIP LOGIC
Q32: Information on grandparents allows us to send appropriate invitations and communications.Does your child have a grandparent?
Yes
PAGE 11: PARENT 3 / GUARDIAN 3 INFORMATION
Q33: CONTACT INFORMATION* Please note: "if different" below means if your address or phone is different from your student's address or phone.
Respondent skipped this question
Q34: PROFESSIONAL INFORMATION
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Q35: Does your employer offer a matching gift?
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Q36: What is your ethnicity?
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Q37: What are your nationalities?
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ECOLE BILINGUE DE BERKELEY STUDENT AND PARENT INFORMATION Q38: What language(s) do you speak at home?
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Q39: Do you need to enter the information of another parent / guardian?
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PAGE 12: PARENT 4 / GUARDIAN 4 INFORMATION
Q40: CONTACT INFORMATION* Please note: "if different" below means if your address or phone is different from your student's address or phone.
Respondent skipped this question
Q41: PROFESSIONAL INFORMATION
Respondent skipped this question
Q42: Does your employer offer a matching gift?
Respondent skipped this question
Q43: What is your ethnicity?
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Q44: What are your nationalities?
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Q45: What language(s) do you speak at home?
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Q46: Information on grandparents allows us to send appropriate invitations and communications.Does your child have a grandparent?
Respondent skipped this question
PAGE 13: GRANDPARENT 1 INFORMATION
Q47: GRANDPARENT 1 Full name
Dorothy Lefkovits
Q48: Does your child need to enter the information of another grandparent?
No
PAGE 14: GRANDPARENT 2 INFORMATION
Respondent skipped this question
Q49: GRANDPARENT 2
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ECOLE BILINGUE DE BERKELEY STUDENT AND PARENT INFORMATION Q50: Does your child need to enter the information of another grandparent?
Respondent skipped this question
PAGE 15: GRANDPARENT 3 INFORMATION
Q51: GRANDPARENT 3
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Q52: Does your child need to enter the information of another grandparent?
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PAGE 16: GRANDPARENT 4 INFORMATION
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Q53: GRANDPARENT 4
PAGE 17: EMERGENCY MEDICAL FORM
Q54: There may be circumstances during the regular operation of the school and Extended Day, and/or during natural disasters, where the school would not be able to contact a parent or legal guardian to obtain permission to administer medical or dental care. Please read and sign the form below to allow such care in these emergency situations.As the parent or guardian of
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Q55: I hereby give consent to Ecole Bilingue de Berkeley to provide all emergency dental or medical care prescribed by a duly licensed physician or dentist for my child(ren). This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my child.En cas d’urgence, j’autorise l’Ecole Bilingue de Berkeley à prendre les mesures nécessaires pour tous soins dentaires ou médicaux dûment prescrits par un dentiste ou un médecin. Ces soins peuvent être donnés pour préserver la vie, un membre ou le bien-être de mon enfant.Enter your full name for signature of Parent or Guardian / Votre nom tient lieu de signature du Parent ou Tuteur
Respondent skipped this question
Q56: Please provide us with CURRENT MEDICAL CONDITIONS or ALLERGIES for your child.(Please contact the school during the year with any updated changes to your child’s medical conditions).
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ECOLE BILINGUE DE BERKELEY STUDENT AND PARENT INFORMATION Q57: CURRENT MEDICAL CONDITIONS or ALLERGIES for your child
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Q58: Healthcare Provider
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Q59: In the event of an emergency, it may be necessary to evacuate the campus. Please list below the names of individuals to whom the school can release your child in the event a parent or guardian is not able to come to campus. This list may be modified at any time.
Respondent skipped this question
PAGE 18: ACTIVITY PERMISSION
Q60: The undersigned parent/guardian(s) (“Parent”) of
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Q61: permits Student to attend and participate in all Ecole Bilingue de Berkeley (“School”) activities,events, off-campus travel/transportation, field trips, sporting events and other schoolsponsoredactivities, some of which involve a heightened risk of injury.Parent understands that there are inherent risks of serious bodily injury and property damageinvolved in all of the above activities and travel. On behalf of Student, Parent voluntarily assumesand accepts such risks of personal injury and property damage arising from Student's attendance andparticipation in such activities and travel, and agrees to assume financial responsibility for emergencycare and services for Student, including rescue and transportation services, if not covered by theSchool’s student accident insurance.This express assumption of risk and release do not apply to liability for gross negligence orintentional injury, and are not intended to apply to School’s insurer or non-agent third parties.This consent shall continue in effect from year to year as long as Student is a student of the School,unless the undersigned subsequently notifies the Lower School Head or Middle School Head in writing that this ongoingauthorization has been terminated.Enter your full name for signature of Parent or Guardian / Votre nom tient lieu de signature du Parent ou Tuteur
Respondent skipped this question
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