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Express Program Enrollment Form

1 - Primary Billing Responsibility Parent/Guardian Information:
* Required Field
* First Name   * Last Name  
MI   * Email  
* Address   * SSN 123456789  
* City   Home Phone (123)456-7890  
* State   Work Phone (123)456-7890  
* Zip 12345 or 12345-1234   Cell Phone (123)456-7890  
Employer   Work Hours From HH:MM  
  Work Hours To HH:MM  
 


2 - Parent/Guardian Information:
 
First Name   Last Name  
Middle   Email  
Address   SSN 123456789  
City   Home Phone (123)456-7890  
State   Work Phone (123)456-7890  
Zip 12345 or 12345-1234   Cell Phone (123)456-7890  
Employer   Work Hours From HH:MM  
  Work Hours To HH:MM  
 


Persons (OTHER THAN PARENT/GUARDIAN) authorized to pick up child:
           First Person            Second Person
First Name   First Name  
Last Name   Last Name  
Relation to Child   Relation to Child  
Address   Address  
City   City  
State   State  
Zip 12345 or 12345-1234   Zip 12345 or 12345-1234  
Phone (123)456-7890   Phone (123)456-7890  
 


In an emergency and Parent/Guardian cannot be contacted, notify:
* Required Field          First Person            Second Person
* First Name   First Name  
* Last Name   Last Name  
Relation to Child   Relation to Child  
Address   Address  
City   City  
State   State  
Zip 12345 or 12345-1234   Zip 12345 or 12345-1234  
* Phone (123)456-7890   Phone (123)456-7890  
 


Persons NOT authorized to pickup your child:
           First Person            Second Person
First Name   First Name  
Last Name   Last Name  


Register children
Please click the 'Continue' button below to register a child.



Express provides equal opportunities in education and employment and does not discriminate on the basis of race, religion,
color, national origin, gender, age, marital status, or disability in accordance with Title VI and VII of the Civil Rights Act of
1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, The Americans with
Disabilities Acts of 1990, and any applicable Washington State laws against discrimination. Spokane Public Schools
recommends that each child participating in the Express program be covered by insurance. Express does not provide
medical/dental insurance to cover injuries to students. The district has arranged for a selected accident insurance plan to
provide affordable coverage that parents can elect to purchase. Please contact your school office for more information if you
are interested. Parent/Guardian understands it is his/her responsibility to provide and purchase adequate insurance coverage
for his/her child when participating in the Express program, through either a private insurance carrier or the plan arranged
for parent's/guardian's consideration by the district.