Parent's Name (Last, First) *

What is your preferred language? *

In what county do you live?

If "Other", please specify

Phone Number 1 (NO DASHES OR SPACES) *

Phone Type 1 *

Phone Number 2 (NO DASHES OR SPACES)

Phone Type 2

Parent email address (THIS is our primary method of contacting you.) *

Name of other adult who may attend (Last, FIrst)

Other adult's email address (This will be another method of contacting you.)

What elementary school do your children attend, or will they attend once they are old enough, and assuming you are still living at your current locaion? *

This program is intended for children from birth to 5 years old, but older siblings are welcome. In order for us to properly prepare for these classes, please provide information for each child who will attend with you.

Information for first child

First child's Name *

First Child's Date of Birth (MM/DD/YYYY)

First child's age *

First child's gender identity *

First child's ethnicity *

First child's race (select all that apply) *

If first child is 'other', please specify

Information for second child

Second Child's Date of Birth (MM/DD/YYYY)

Second child's age

Second child's gender identity

Second child's ethnicity

Second child's race (select all that apply)

If second child is 'other', please specify

Information for third child

Third Child's Date of Birth (MM/DD/YYYY)

Third child's age

Third child's gender identity

Third child's ethnicity

Third child's race (select all that apply)

If third child is 'other', please specify

Parent Permissions and Agreements

Please note that if we receive applications for more families than we can accomodate, we may maintain a wait list in case of unexpected vacancy.

Including yourself, how many adults or children age 14 or over will attend with you to assist these children? *

It is possible that this program may be publicized and that your child(ren)'s names and photographs might be recorded for use in a public way, to demonstrate participation in our program.

May we have permission to use your child(ren)'s name? *

Yes

May we have your permission to use your child(ren)'s photograph? *

Yes

I understand a parent is required to attend each class with my child(ren). *

Yes

I understand my child(ren) is expected to follow the teacher's instructions at all times. *

Yes

I agree to abide by normal GCPS standards and have my child(ren) in class ON TIME and for both 4 week session. *

Yes

I agree to release Interlocking Communities, Inc (ICI) from all liability while my child is attending these classes. *

Yes

I accept that, regardless whether I understand and agree to this and each of the previous four statements, if I respond 'no' to any of the statements, my family) may not be admitted to the RB5 classes.

Yes

By submitting this electronic application, I understand and agree that my child's, or my, failure to comply with any of these guidelines could cause my child to be removed from the RB5 program.

I Agree

I Disagree

The last date to apply is December 20, 2024.

We will notify you by email no later than the week of January 12, 2025 whether your family has been enrolled or put on our waiting list.

Please check your email during that time, and throughout the program, for our messages and reply promptly.