Lights On Registration Form
One Registration per Student

Please provide the following information as completely as possible. If you have any questions please contact the Lights On in Lander office at 332-4240

Student First & Last Name

Grade

POWER HOUR AND ENRICHMENT SCHEDULE
Please check ALL days that apply

	Monday	Tuesday	Wednesday	Thursday	Friday
CHESS CLUB (All Grades) 7:15-7:45am
CUB POWER HOUR (All Grades) 7:00-7:45am
CUB POWER HOUR (6th Grade) 3:45-4:45pm
CUB POWER HOUR (7thh & 8th Grade) 3:45-5:00pm

Activities Schedule
CHESS CLUB (All Grades):                      Monday thru Friday 7:15am to 7:45am
CUB POWER HOUR (All Grades):            Monday thru Friday 7:00am to 7:45am
CUB POWER HOUR (6th Grade):            Monday, Tuesday, Thursday 3:45pm to 4:45pm
CUB POWER HOUR (7th & 8th Grade): Monday, Tuesday, Thursday 3:45pm to 5:00pm

Please provide the following information as Emergency Contact Information

Parent / Guardian

Home Address

Home Phone

Work Phone

Cell Phone

Lander Emergency Contact

Emergency Phone Number

Email Address (Lights On really appreciates the opportunity to communicate via email.)

Physical Limitations / Special Needs

Medications, if any

List all persons AUTHORIZED to pick up your child:

List all persons NOT AUTHORIZED to pick up your child:

	Yes	No
Was your child referred to the program?
May we photograph and/or video your child during Lights On Activities?
Would you be interested in sitting on our Advisory Council?

By filling out the following application, I agree to the following terms:

I hereby authorize Fremont County School District #1 to release pertenent information (i.e., Emergency Information, Health Information & Personal Information) regarding the above named student(s) to Lights On in Lander personnel as needed. I also authorize officials to take whatever action is deemed to necessary in their judgement for the helath of my child. I will not hold them financially responsible for the emergency care and/or transportation of my child.

My child qualifies for the Free & Reduced Lunch Program

Yes

In order to best serve your child if he/she has an IEP, may we access that information and/or be a part of the IEP team?

Yes

N/A

Please list your questions or concerns!

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