KISR! Enrichment Referral Form

KISR! Enrichment Referral Form

Please Note: This form is reserved for students who are both attending a Cincinnati Public School AND associated with HAMILTON County foster care.
Student Name*

First NameLast Name
Student School*
Grade*

Kindergarten1st2nd3rd4th5th6th7th8th9th10th11th12th
Student Birth Date*

MonthDayYear
Date
Phone Number Where Student Can Be Reached

Area CodePhone Number
Student Email (if applicable)
example@example.com
Gender*

MaleFemaleI don't Know
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Caregiver Name*

First NameLast Name
Caregiver #2 Name

First NameLast Name
Caregiver Phone Number

Area CodePhone Number
Caregiver Email
example@example.com
Does child have any medical condition(s), special needs, and/or allergies?*

YesNoI don't know
If yes, please explain.
Is the child currently participating in any after-school activities?*

YesNoI don't know
If yes, please explain.
Select Student's Interests*

ArtBaseballBasketballBowlingBoxingCheerleadingCross CountryDanceFootballGolfLacrosseMartial ArtsMusicPhotographySoccerSoftballSwimmingTennisTheaterTrack & FieldTutoringVolleyballWorkWrestlingNONE ON THIS LIST
Use this field to address interests not listed above or list specific programs you would like to enroll this student in.
I would like to enroll this student in an activity that is: (select ALL that apply)*

ONLY offered by their schoolONLY located at their schoolOffered by an external vendorI am open to different vendors and locationsI am not a primary decision maker for this student
Name of person making this referral*

First NameLast Name
Email of person making this referral*
example@example.com
Please share any additional details you feel are related to this child participating in after-school activities.
Should be Empty: