RTV VSK/VST Application

Program*
Program Site*
Child’s Name*
Child’s Grade*
Child’s Gender*
- Female
- Male
Date of Birth*
Child’s Mailing Address*
Street Address City 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 State ZIP Code
Parent/Guardian Phone Number*
Parent/Guardian Email Address*
Parent/Guardian Relationship Status*
Parent/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.
Comments
This 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