PERSONAL INFORMATION

Child's Name

Grade

Student ID

School

-

PARENT/GUARDIAN INFORMATION

Name

Relationship to Child

Current Address

Daytime Phone Number

Email Address
[parent email* email]

-

ALTERNATE PARENT/GUARDIAN INFORMATION

Name (Optional)

Relationship to Child (Optional)

Current Address (Optional)

Daytime Phone Number (Optional)

Email Address

-

EMERGENCY CONTACT

Name

Relationship to Child

Address

Cell Phone

-

MEDICAL INFORMATION

Medicines Taken

Allergies/Medical Conditions

Family Physician

Family Physician Phone Number

Insurance Provider

Policy Number

-

TRANSPORTATION INFORMATION
At the end of the daily program AND in the event that the program is canceled or dismissed early because of weather or any other reason, please have my child: (PICK ONE)

WALK HOME BY HIMSELF/HERSELFPICKED UP ON TIME

If you would like you child to "PICKED UP ON TIME", please list the people who are allowed to pick your child up.

Name 1

Phone 1

Name 2

Phone 2