Child Information
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| Childs Name: |
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Birth Date: |
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| Childs Name: |
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Birth Date: |
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Parent/Guardian Information
(Please list parent/guardian affiliated with Evergreen first)
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| Parent/Guardian: |
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| Home Address: |
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| City: |
State: Zip: |
| Evergreen ID#: |
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| Home Phone: |
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Day Phone:
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Ext: |
| Email Address: |
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Relationship to Evergreen (check all that apply)
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| Student Status: |
Enrolled or Planning to Enroll |
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Freshman Sophomore Junior Senior Grad Student |
| Employee: |
Evergreen Staff or Faculty or Applying at Evergreen Other: |
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Parent/Guardian
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| Parent/Guardian: |
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| Home Address: |
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| City: |
State: Zip: |
| Evergreen ID#: |
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| Home Phone: |
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Day Phone:
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Ext: |
| Email Address: |
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|
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| Student Status: |
Enrolled or Planning to Enroll |
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Freshman Sophomore Junior Senior Grad Student |
| Employee: |
Evergreen Staff or Faculty or Applying at Evergreen Other: |
Desired Care Schedule
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| Desired date of enrollment: |
| Estimated date of withdrawal: |
Additional information about your child or plans that may affect your childs registration or priority on the wait list:
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