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ASEP Registration Form

STOP--Envision Children is no long taking applications for the 2022 Academic Summer Enrichment Program. 

We have a long waitlist and are not taking anymore names for consideration!

Student Information
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$
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First Name
Last Name
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(lunch number, 6 digits, starts with 7):___________________
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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Would you like your child to receive a free breakfast and lunch at the program?

I have additional children who will not be attending the ASEP that I would like to participate in the free breakfast and lunch program. (Note parent must provide them transportation to and from the meals). Their names and ages are:
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Please list name and phone number of the person the Northwest Transportation Department can contact about your transportation needs.

If you child needs transportation from a location other than your home address (must be in the district), please list it here. Need--Street Address, City, State and Zip Code

Please list the name of the person and their phone number who will meet your child at the alternate drop off location.
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Please type your name and the date you are signing this document. This will serve as your electronic signature .

As parent/guardian, I authorize Envision Children and/or their authorized agents to publicly to release my child’s name, use video tapes, photography and otherwise publish or cause to be published the information relevant to his/her achievements. This information may be used in local, regional, state or national publications of Northwest Local School District as well as appropriate newspaper or other news publications.