New Page — OIC OF NEW BRITAIN

Middle & High School Registration Form

Name

First Name

Last Name

Gender

Male

Female

Date of Birth

Age

Childs Race/Ethnicity?

Grade

School

For which program are you registering your child?

Student ID# (office use)

Sasid# (office use)

Home Address

City

State

With whom does the registering child currently live with most of the time:

Is your child on any medication?

If so, please list

Lunch: (check one)

Parent/Guardian Info

Relationship

Home/Cell

Emergency Contact

Relationship

Phone

Specify any health problems

Is your child in Special Education

Other than Parent or Guardian, is anyone else authorized to pick up your child?

Name

Phone/Cell

Will your child be participating in any other activities or sports? If so please list

If so, what days do they meet

I hearby give OIC permission to photograph and/or video tape my child for educational or promotional purposes

Parent/Guardian Signature

Date

Students will be bussed from their day school to OIC located on 114 North St, directly after school: Bus home from program or pick up time will be: 5:15 PM (Monday's & Tuesday's) 5:00 PM (Friday's)

Text Area

Opportunities Industrialization Center (OIC) of New Britain is a non-profit (501(C)(3) nonprofit organization providing community services through federal, state and local funding sources. We are committed to helping those with barriers to self-sufficiency through our Young Adult Workforce Development initiatives as well as provide youth career awareness and readiness programming to middle and high school students.