FAMILY INFO
Student(s)’s Name(s): __________________________________________________
Student(s)’s Teacher(s): ________________________________________________
School & Grade(s) _____________________________________________________
- Parent/Guardian Name: _______________________________________________________________________
Phone# (home): __________________________(cell):___________________________
Email: __________________________________________________________________
- 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):
- Contact Person: _________________________________________________
Phone # ___________________________________________________
Relation to child(ren): _______________________________________
- Contact Person: _________________________________________________
Phone # ___________________________________________________
Relation to child(ren): _______________________________________
- Contact Person: _________________________________________________
Phone # ___________________________________________________
Relation to child(ren): _______________________________________
Parent/Guardian Signature__________________________ Date_________________