RTV VSK/VST Application Program*After School VSK (K – 5)After School VSY (6 – 8)Summer Camp VSK (K – 5)Summer Camp VSY (6 – 8)Program Site*Dr. Williams A. ChapmanCoconut Palm AcademyLeisure City K-8 CenterPine Villa ElementaryChild’s Name* Child’s Grade*Kindergarten1st2nd3rd4th5th6th7th8thChild’s Gender* Female Male Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child’s Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child’s Race* American Indian or Alaska Native Asian Black Native Hawaiian or Other Pacific Islander White Two or More Races Parent/Guardian Name* Parent/Guardian Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Phone Number*Parent/Guardian Email Address* Parent/Guardian Relationship Status*SingleMarriedWidowedDivorcedSeparatedParent/Guardian Employment Status* Parent/Guardian Income* Emergency Contact Name* Emergency Phone Number* Emergency Email Address* Pick Up Authorization* If there is any person’s that is NOT authorized to pick up your child, please list them here. If there are no names you wish to include, please type N/A.After School Parent Handbook Acknowledgement Form Upload Please download, sign and upload this form here.After School Parent Handbook Acknowledgement Form Upload Please download, sign and upload this form here.Summer Camp Parent Handbook Acknowledgement Form Upload Please download, sign and upload this form here.Summer Camp Parent Handbook Acknowledgement Form Upload Please download, sign and upload this form here.Student Enrollment Contract & Media Release Form Please download, sign and upload this form here.Assurance* I attest that all the information submitted in this application is correct.PhoneThis field is for validation purposes and should be left unchanged. Recapturing the Vision 11205 South Dixie Hwy Suite 201 Miami FL 33156 Phone: 305.232.6003 Email: info@rtv.org Newsletter Contact Us Your name Please enter your name. Your email Please enter a valid email. Your message Please enter a message. Please check the captcha to verify you are not a robot. Send Message Sent! Message failed. Please try again.