Register

FAMILY INFO

 

Student(s)’s Name(s): __________________________________________________

 

Student(s)’s Teacher(s): ________________________________________________

 

School & Grade(s) _____________________________________________________

 

  1. Parent/Guardian Name: _______________________________________________________________________

 

Phone# (home): __________________________(cell):___________________________

 

Email: __________________________________________________________________

 

  1. Parent/Guardian Name: _______________________________________________________________________

 

Phone# (home): ___________________________(cell):__________________________

 

Email/Address: _____________________________________________________

 

Health and Medical Information

Please specify any medical conditions or allergies your child(ren) may have and/or any activity that your child should not be allowed to participate: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

In the event that I cannot be reached in an emergency, I hereby give permission to hospital

personnel to administer treatment to my child(ren).

 

Signed______________________________________ Date____________________

PICKUP & EMERGENCY CONTACT  INFO

 

In the event of an emergency and I cannot be contacted or cannot pick?up my child(ren)

from After?School, the following person(s) are authorized to care for and or retrieve my

child(ren):

 

  1. Contact Person: _________________________________________________

 

Phone # ___________________________________________________

 

Relation to child(ren): _______________________________________

 

  1. Contact Person: _________________________________________________

 

Phone # ___________________________________________________

 

Relation to child(ren): _______________________________________

 

  1. Contact Person: _________________________________________________

 

Phone # ___________________________________________________

 

Relation to child(ren): _______________________________________

 

 

Parent/Guardian Signature__________________________ Date_________________