Enrollment – Global Outreach Charter Academy

GOCA-RIZING Program Enrollment Form for Eligible Students*

August 20, 2018 – May 25, 2019

Monday – Thursday (except early release days and holidays) Program starts at 3:06pm and ends at 6:06pm. It will be the parent’s responsibility to arrange a form of transportation for the child. Students are to be picked up at 6:06pm to avoid late fee. Program Enrollment Form

Child’s First Name*

Child’s Last Name*

Student ID

Child’s Birth Date*

Child’s Age*

Grade for 2018-2019 year*

Mother's Fields

Mother’s / Legal guardian First Name*

Mother’s / Legal guardian Last Name*

Mother’s / Legal guardian Email Address*

Mother’s / Legal guardian Mobile Phone*

Allowed to pick up phone?*

YES
NO

Mother’s / Legal guardian Home Address*

Street Address Address Line 2 City State ZIP Code

Father’s Fields

Father’s / Legal guardian First Name*

Father’s / Legal guardian Last Name*

Father’s / Legal guardian Email Address*

Father’s / Legal guardian Mobile Phone*

Allowed to pick up phone?*

YES
NO

Address is the same as mother*

YES
NO

Father’s / Legal guardian Home Address

Street Address Address Line 2 City State ZIP Code

Special Comments/Notes

Does your child have any food allergies?*

YES
NO

If YES, please list

Please list the contact information of people to be notified and permitted to remove child:

First name	Last name	Cellphone	Relationship

Nutritional Snacks Requirement

During the program, a Nutritional Snacks will be served, which include, but are not limited to, animal crackers, cheese sticks, PB&J sandwiches, low-fat yogurt, pretzels, and goldfish along with apple juice. Parents are allowed to provide additional/supplemental snacks.

Authorization for Emergency Care

In the case of accident or serious illness and the school is unable to reach me, I hereby authorize the school to contact the physician. The school may make whatever arrangements necessary to provide care and treatment for my child. In case of accident or illness where immediate treatment of my child is not necessary but he/she is unable to remain at school, the school will contact me to arrange transportation for my child. If the school is unable to reach me, I authorize the school to contact one of the individuals listed in the Enrollment Form and request them to come to the school and transport my child home.

General Release of Liability

By signing below, I hereby release and forever discharges Global Outreach Charter Academy, the Duval County School Board, the Department of education, the City of Jacksonville, their offices, agents, servants, and employees, from all claims and demands while participating in activities sponsored by The 21^st Century Grant at Global Outreach Charter Academy.

Enrollment is subject to seat availability and program director approval

*go to https://www.goca.us/eligibility/ for eligibility requirements By signing bellow, I am agreeing to all terms and conditions of the program, as well as full commitment to the entire duration of the program. All absences must be excused by the program director’s written approval.

TERMS OF ACCEPTANCE and SIGNATURE*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Electronic Signature (Please type your First Name)*

Electronic Signature (Please type your Last Name)*

Signature

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