Program Registration LinkedInThis field is for validation purposes and should be left unchanged.Parent / Guardian InformationName(Required) First Last Email Address(Required) Phone Number(Required)Child InformationChild's Full Name(Required)Child's Date of Birth(Required) Current School NameWhich program are you applying for?(Required)Select a program...Family R.E.A.D.Y.Inspired MindsSaturday AcademyPre-K JumpstartFamily R.E.A.D.Y. Program DetailsPlease complete the section below for the Family R.E.A.D.Y. program.How many children will be participating?(Required)Ages of Participating Children(Required)Areas Where You'd Like Support(Required) Reading & Literacy Math Skills Homework Help Study Habits Parent Engagement Strategies Other Family GoalsInspired Minds Program DetailsPlease complete the section below for the Inspired Minds program.Current Grade Level(Required)Select grade...6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeSTEAM Interests(Required) Science Technology Engineering Arts Mathematics Computer Science Robotics Other Career or Academic GoalsSaturday Academy Program DetailsPlease complete the section below for Saturday Academy.Current Grade Level(Required)Select grade...3rd Grade4th Grade5th GradeSubjects Needing Support(Required) Reading Writing Math Science Social Studies Test Prep Other Additional NotesPre-K Jumpstart Program DetailsPlease answer the eligibility questions below.What is your child's current age?(Required) Under 3 Years 3 Years 4 Years 5 Years 6 Years or Older Emergency ContactEmergency Contact Name(Required)Relationship to Child(Required)Emergency Contact Phone Number(Required)Student Health InformationHealth Conditions or AllergiesHow did you hear about Soaring As Eagles?Select one...Word of mouth / Friend or familySocial media (Facebook, Instagram, etc.)WebsiteSchool or teacherCommunity eventFlyer or brochureOtherConsent & Agreement(Required) I confirm that the information provided is accurate and I agree to the program's participation guidelines.By submitting this form, you agree to allow Soaring As Eagles to use the provided information for program administration purposes.We're sorry. The Pre-K Jumpstart program is designed for children between the ages of 3 and 5. Based on the age you selected, your child does not meet the eligibility requirements. Please contact us to explore other programs.Is your child fully potty trained?(Required) Yes No We're sorry. Children must be fully potty trained to participate in the Pre-K Jumpstart program. Please contact us if you have questions.Additional Child InformationChild's GenderSelect...MaleFemaleNon-binaryPrefer not to sayChild's RaceSelect...American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMultiracialPrefer not to sayChild's Ethnicity Hispanic or Latino Not Hispanic or Latino Prefer not to say Home Address(Required)Child Health InformationDoes your child have any known food or environmental allergies?(Required) Yes No Please describe your child's allergiesDoes your child have any medical conditions we should be aware of?(Required) Yes No Please describe your child's medical conditionsHas your child received any developmental evaluations or services?(Required) Yes No Please describe the evaluations or services receivedTransportationDo you have reliable transportation to bring your child to the program?(Required) Yes No Would you like to be connected with transportation support resources? Yes No Parent / Guardian Additional InformationParent / Guardian GenderSelect...MaleFemaleNon-binaryPrefer not to sayRelationship to Child(Required)Select relationship...MotherFatherGrandmotherGrandfatherLegal GuardianOtherEmployment StatusSelect status...Employed Full-TimeEmployed Part-TimeSelf-EmployedUnemployedStudentRetiredPrefer not to sayPreferred LanguageSelect language...EnglishSpanishFrenchArabicOtherFamily EngagementHow confident are you that your child is ready for kindergarten? (1 = Not at all confident, 5 = Very confident)(Required) 1 2 3 4 5 What would help your family most? (Select all that apply) Reading resources at home Learning activities for parents Information about kindergarten enrollment Community support resources Other Household InformationTotal number of people in your household(Required)Number of children under 18 in household(Required)Does your household currently receive any of the following benefits? SNAP (Food Stamps) Medicaid / NC Health Choice WIC TANF Housing Assistance Head Start / Early Head Start None Annual Household Income Under $20,000 $20,000 – $35,000 $35,001 – $50,000 $50,001 – $75,000 Over $75,000 Prefer not to say Additional Emergency Contact InformationAuthorizations & AgreementsMedical Emergency Consent(Required) I authorize Soaring As Eagles staff to seek emergency medical care for my child if I cannot be reached.In the event of a medical emergency, I authorize Soaring As Eagles to contact emergency services and seek necessary medical treatment for my child.Media & Photography DisclosureDo you give permission for your child to be photographed or filmed for program purposes (social media, newsletters, reports)?(Required) Yes, I give permission No, I do not give permission Daily Reflection Consent(Required) I agree to receive daily or weekly program updates and reflections about my child's progress.Communication Consent(Required) I agree to receive program communications via email, phone, or text from Soaring As Eagles.We will only contact you regarding program information, updates, and scheduling.Data Sharing Consent(Required) I understand that aggregate (non-identifiable) program data may be shared with funders or partner organizations.No personally identifiable information will be shared without separate written consent.Participation AgreementParticipation Agreement(Required) I have read and agree to the program's participation requirements and policies.I understand that consistent attendance and family involvement are expected. I agree to notify Soaring As Eagles of any changes to my child's information or our participation status.Today's Date(Required) Electronic Signature(Required)By typing your name above, you are providing your electronic signature and agreeing to all terms outlined in this application.
