Lights On Registration Form
One Registration per Student

Host School: North Elementary
Session Dates: Monday, November 28 - Tuesday, December 20
CLOSED: Wednesday,December 21 - Tuesday, January 3
PLEASE NOTE: You only have to complete one registration per student per year, unless you student's contact information and/or schedule changes.

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

Teacher

Grade

School Attending

North

Gannett Peak

Baldwin Creek

Other (LCA, Sunrise, etc.)

POWER HOUR AND ENRICHMENT SCHEDULE
Please check ALL days that apply

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?
Will your child need a late pick up (between 5:30pm and 6:00pm)?

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

No

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

No

N/A

Bus Drop Off Location (5:30 p.m.)

Please list your questions or concerns!

Not Applicable	Wyoming Indian Elementary	Wyoming Indian High School
Hudson City Park	Alco Parking Lot	Lander Game and Fish Parking Lot
Kidz Inc.	School of Origin

	Monday	Tuesday	Wednesday	Thursday	Friday
EARLY BIRD
EARLY BIRD CHESS (NORTH ONLY)
POWER HOUR
ENRICHMENT