EXPRESS PROGRAM ENROLLMENT FORM 1 - Primary Billing Responsibility Parent/Guardian Information: * Required Field * First Name   * Last Name   MI   * Email   * Address   * SSN 123456789   * City   Home Phone (123)456-7890   * State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY   Work Phone (123)456-7890   * Zip 12345 or 12345-1234   Cell Phone (123)456-7890   Employer   Work Hours From HH:MM am pm     Work Hours To HH:MM am pm     2 - Parent/Guardian Information:   First Name   Last Name   Middle   Email   Address   SSN 123456789   City   Home Phone (123)456-7890   State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY   Work Phone (123)456-7890   Zip 12345 or 12345-1234   Cell Phone (123)456-7890   Employer   Work Hours From HH:MM am pm     Work Hours To HH:MM am pm     Persons (OTHER THAN PARENT/GUARDIAN) authorized to pick up child:            First Person            Second Person First Name   First Name   Last Name   Last Name   Relation to Child   Relation to Child   Address   Address   City   City   State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY   State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY   Zip 12345 or 12345-1234   Zip 12345 or 12345-1234   Phone (123)456-7890   Phone (123)456-7890     In an emergency and Parent/Guardian cannot be contacted, notify: * Required Field          First Person            Second Person * First Name   First Name   * Last Name   Last Name   Relation to Child   Relation to Child   Address   Address   City   City   State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY   State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY   Zip 12345 or 12345-1234   Zip 12345 or 12345-1234   * Phone (123)456-7890   Phone (123)456-7890     Persons NOT authorized to pickup your child:            First Person            Second Person First Name   First Name   Last Name   Last Name   Register children Please click the 'Continue' button below to register a child. Express provides equal opportunities in education and employment and does not discriminate on the basis of race, religion, color, national origin, gender, age, marital status, or disability in accordance with Title VI and VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, The Americans with Disabilities Acts of 1990, and any applicable Washington State laws against discrimination. Spokane Public Schools recommends that each child participating in the Express program be covered by insurance. Express does not provide medical/dental insurance to cover injuries to students. The district has arranged for a selected accident insurance plan to provide affordable coverage that parents can elect to purchase. Please contact your school office for more information if you are interested. Parent/Guardian understands it is his/her responsibility to provide and purchase adequate insurance coverage for his/her child when participating in the Express program, through either a private insurance carrier or the plan arranged for parent's/guardian's consideration by the district.