Editing previous response:

Please fix the highlighted areas below before submitting.

ASPIRA ACAP-E Program SY 26-27

ASPIRA Children's Achievement Program Esperanza Interest Form SY 26-27

Location: EZPERANZA Charter School

201 W. Hunting Park Avenue

Philadelphia, PA 19140

Student Information

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Date of Birth*

Answer required for "Date of Birth"

Grade*

Answer required for "Grade"

Current School*

Answer required for "Current School"

Parent Information

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Street Address

Answer required for "Street Address"

City

Answer required for "City"

Zip/Postal

Answer required for "Zip/Postal"

Email Address*

Answer required for "Email Address"

Phone Number*

Number Required

Health and Safety

Allergies or Medical Needs*

Answer required for "Allergies or Medical Needs"

Emergency Contact Name and Phone*

Answer required for "Emergency Contact Name and Phone"

Authorized Pick-Up Persons*

Answer required for "Authorized Pick-Up Persons"

Does your child have an up to date health assessment?*

Answer required for "Does your child have an up to date health assessment?"

Yes

Program Fit

What are you hoping your child gains from this program?*

Answer required for "What are you hoping your child gains from this program?"

Availability and Commitment

Will your child attend 5 days a week?*

Answer required for "Will your child attend 5 days a week?"

Yes

Final Acknowledgement

Please check to confirm:*

Answer required for "Please check to confirm:"

I understand this is an interest form and does not guarantess enrollment.

I understand that selected families will be contacted with the next steps.

By signing below, I confirm that I have read and understand the information provided in this Summer Program Interest Form. I understand that this form is for interest purposes only and does not guarantee enrollment or placement in the program.*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"