HESC Student Registration Form

Student Registration Form

Registration due by Friday, June 7, 2019.
Twin Rivers Unified School District students have priority.

1. Student Information

* Indicates required field

Last Name, First Name *

Date of Birth *

Age *

Gender *

2019-2020 Grade Level *

Twin Rivers Unified School District *

Specify "Other School" *

Home Address *

City, State *

Zipcode *

Phone Number *

Email Address *

2. Emergency Contact Information

Parent/Guardian *

Relationship *

Contact Number *

Parent/Guardian *

Email Address *

Relationship *

Contact Number *

3. Medical Information

Email Address *

In the event of an accident or other emergency when a parent/guardian is unavailable, I hereby authorize the school to make necessary arrangements for my child to receive medical or hospital care, including transportation. I agree to pay all costs incurred. Under the above circumstances, I further authorize the physician named below to undertake such care and treatment of my child as necessary. In the event said physician is not available, I authorize such care and treatment to be performed by a licensed physician or surgeon.

Doctor's Name *

Address *

Health Coverage *

Phone Number *

City, State, Zip Code *

Medical ID # *

Hospital *

List any medications or special health care procedures: *

4. Student Survey

Please answer the following questions as best as you can.

(a) Is your child in any of the following programs or receiving any of the following services?

List any food allergies: *

(b) Check the HYPU programs your child has participated in.

(c) Select the top 3 most desirable activity that your child is most interested in participating.

Most Desirable Activity *

Second Most Desirable Activity *

Third Most Desirable Activity *

(d) Student Hmong Language Fluency

(e) What are your expectations of the program?

Comment *

5. Student Photo/Video/Product Release

(f) What would you like us to know about your child?

Comment *

I hereby give the the District and summer program, its employees, assigns and agents permission to utilize and/or publish work my child produces during summer activities and to utilize and/or publish photographs or video taken during program activities or at special events sponsored by the District and the summer program where my child may appear. These photographs, student products, and video materials may be used in publications, audiovisual presentations, promotional literature, advertising, or any other manner without compensation to the child, parents, or guardian.

Choose Any *

Yes No

Initials *

6. Parent Signature

By signing, you have provided accurate information about your child and acknowledge receipt of the program policies and rules.

Electronic Signature *

Date of Signature *

Submit

​Student Registration Form

1. Student Information

2. Emergency Contact Information

3. Medical Information

4. Student Survey

5. Student Photo/Video/Product Release

6. Parent Signature

Student Registration Form