Dolton West School District 148
Express Yourself Summer Program
K-4th Grade
2017 Application and Contract
(Submit completed application by Friday, May 12, 2017)
Current School/ Grade
Student’s Name
Address
City/State/Zip Code
Home Phone ( Must be a current number to be reached at all times)
Parent/Guardian’s Name
Work/Cell Number
List any medical conditions
How will your child be getting home from the Express Yourself Summer Program? Circle one.
MY CHILD WILL WALK HOME
MY CHILD WILL BE PICKED UP
In case of emergency contact
Emergency name #1
Relationship to Child
Home/Cell Number
Work Number
Emergency name #2
Home/Cell Number
Relationship to Child
Work Number
Emergency name #3
Home/Cell Number
Relationship to Child
Work Number
Parent/Guardian Contract
I understand the following about the District 148’s 2017 Express Yourself Summer Program
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The application/contract is due by Friday, May 12, 2017.
Summer session begins on Monday, June 12, 2017, and ends on Thursday, July 20,
2017.
Sessions are Monday, Tuesday, Wednesday, & Thursday 8:30 a.m. – 12:30 p.m.
Breakfast & Lunch will be provided
Sessions will be held at:
o Riverdale School, 325 West 142nd Street, Riverdale Il 60827 (708) 849-7153
for students from Riverdale School
District 148 guidelines for behavior outlined in the District Handbook are in effect
throughout the literacy launch program.
My child may be dismissed from the program due to tardiness, absences, and/or
failure to cooperate with staff.
Parent Signature: _____________________________
Date_______________