Main Registration part 1

Child/Parent/Guardian Information

Child's Name

First Name*

Middle Name

Last Name*

Birth Day

Required* //

Age

Required*

School

Required*

Grade

Required*

Address

Street 1*

Street 2

City*

State*

Zip*

E-mail

Required*

This is required because this is our primary form of communication when not in session.

Parent or Guardian Name - Mom

First Name*

Last Name*

Phone

Required* -- ext

Employer Name and Address

Street 1

Street 2

City

State

Zip

Parent or Guardian Name - Dad

First Name*

Last Name*

Phone

Required* -- ext

Employer Name and Address

Street 1

Street 2

City

State

Zip

Emergency Contacts

Emergencies may necessitate contact with designated individuals who can assume responsibility for the welfare of your child when you are available. Please review this form and carefully choose people who you feel should be called in an extreme emergency when you cannot be reached. You must provide the names and phone numbers of three people. It is imperative that your selection is based on several criteria: 1. Be sure that individuals are in close proximity to the Study Hall and are responsible individuals who your child trusts. 2. Notify these individuals that you have designated them to serve in this capacity on this form. For our program, please provide three (3) names and full addresses other than parents/guardians:

Contact 1

First Name*

Last Name*

Contact 1 Phone

Required* -- ext

Contact 2

First Name*

Last Name*

Contact 2 Phone

Required* -- ext

Contact 3

First Name

Last Name

Contact 3 Phone

-- ext

Medical Information

Please provide information on Hospital choice, allergies, any physical limitations and Doctor information

Hospital Choices

Please provide 2 choices

Consent and Agreement for Emergencies
Required*

Checking yes to this As parent/guardian, I give consent to have my child, receive first aid by the child care staff, and if necessary be transported to receive emergency care.*

Checking indicates consent

I also authorize the Director or Director Designee to contact my child’s health care provider to alert him/her to my child’s situation. I understand that I will be responsible for all charges not covered by insurance. I give consent for the emergency contact person listed on Emergency Form Part I to act on my behalf until I am available. I agree to review and update this information whenever a change occurs and at least every six (6) months.

Allergy/Medical Information

Please describe any medical information that might be useful to the staff in dealing with your child. List below. If none write none.*

Food, Drug, Beverages, Insects and Vegetation.

Activities

Please List any physical limitations, Activity preferences and any special needs*

Doctor Name

First Name

Last Name

Doctor Address

Street 1

Street 2

City

State

Zip

Insurance Carrier and Policy #

Main Registration part 2

	Please go to Registration Forms to print out Main Registration Online part 2 and bring in with you or pick up copy at the Study Hall.
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Main Registration part 1

Online Giving