East Wichita Homeschool CoOp

First Name

Last Name

Birthdate

Grade

Student Email/Username

Child Phone (Optional)

Enable Text Messages

Child is able and agrees to receive text messages at this number.
We understand carrier message and data rates may apply.

Medical Notes/Allergies? Yes No

Upload Child Photo (Optional) .jpg, .gif or .png

Gender

*	Does this child have any allergies/ things we need to know? Please list anything that might help a teacher to teach this student.

Many Emails: Would you like to receive notifications IMMEDIATELY? Yes No

Delivery Type Whole Thread New Part Only

Daily Digest: Would you like to receive notifications ONCE A DAY? Yes No

Additional Questions

Payment Instructions

Payment is due to Libby Pritchett by cash or check, or to Kristin Shank by Cash App.

East Wichita Homeschool Coop