Main Registration

Child/Parent/Guardian Information
Child's Name
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Birth Day //
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Age
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Sex
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School
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Grade
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Address
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E-mail
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 This is required because this is our primary form of communication when not in session.
Parent or Guardian Name - Mom
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Phone -- ext
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Business Phone Number
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Parent or Guardian Name - Dad
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Phone -- ext
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Business Phone Number
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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
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Contact 1 Phone -- ext
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Contact 2
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Contact 2 Phone -- ext
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Contact 3
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Contact 3 Phone -- ext
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Medical Information
Please provide information on Hospital choice, allergies, any physical limitations and Doctor information
Hospital Choices
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Consent and Agreement for Emergencies
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 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
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 Food, Drug, Beverages, Insects and Vegetation.
Seizure Action Plan
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 Does your child have seizures? If so please fill out Seizure Action Plan https://saintanthonypadua.org/media/1/18/SeizureActionPlan.pdf
Insurance Carrier and Policy #
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List any information (special needs/IEP) that may be pertinent in caring for your child: (If Yes, additional form need to be completed)
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Do you need a Tuition Payment Plan
Select one
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Policies and Agreements
OUR POLICY ACKNOWLEDGEMENT As enrolled parents, it is our obligation to inform you of the following policies set forth by the St. Anthony Study Hall Program. To understand the policies, we set please click on link Policies. By clicking the "Yes", I understand that all policies set forth by the daycare are available for me to always review. The Policies are Information to Parents, Rules and regulations policy, Release policy, Expulsion policy, Communicable disease policy, Technology and social media policy, Medication administration policy, Disruptive behavior policy, Homework policy, and Late pick up policy. To see the policies, go to our website https://www.saintanthonypadua.org/66.
Acknowledgement Document https://www.saintanthonypadua.org/media/1/18/Policy%20Acknowledgements.pdf
Policy Acknowledgement
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Child Custody Agreement
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Subsidized Families Only
Are you currently enrolled in Child Care Solutions?
Select One
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Photo Consent and Walking Trips Consent
Photo consent
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 As parent/guardian, I understand that archival and promotional media (pictures, video, audio, etc.) will be taken during this event. I give permission for my son/daughter's image and/or other appropriate media content to be used for promotional materials (brochures, newsletters, web page, calendars, Power Points, etc.) in promoting St. Anthony Study Hall and/or Summer Break Programs.
Consent and Liability Wavier for Walking trips
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 I grant permission for my child to participate in trips, walking, attended through the St. Anthony Study Hall/Summer Break Program. I understand that the walking routes include no safety hazards and that the walks will be near St. Anthony of Padua Church, such as Cypress Park and Spray Park and walks to and from the bus stop. I agree on behalf of myself, my child's other parent(s) and/or guardian(s), and my child named herein, to waive claim or claims that may be derived from any incident, accidents, or injury sustained resulting from participation in the trips during the enrolled programs and related activities. I further agree to indemnify, defend, and hold harmless: program sponsors St. Anthony of Padua Church and St. Anthony Study Hall Program; participating diocese, parishes, and schools; agencies and organizations working collaboratively with the program; all staff, volunteers, representatives, and adult supervisors of the afore mentioned institutions. I consent to the modes of transportation employed by the program staff and representatives.
Study Hall Rules
CHILDREN STUDY HALL FLOOR RULES The following is a list of rules we use while children are in our facility: Please review these rules with your child and be sure that they understand them. 1) DO NOT put your hands, feet, or anything else where it doesn’t belong and keep your hands and any other body parts to yourself. 2) Must always stay in your group. 3) Children are only allowed to stay in the hall. 4) No electronics 5) Not allowed in kitchen, office, or storage area 6) No running in the hall 7) No sitting on tables or going under the tables. 8) No hand stands or tumbling on the floor. 9) No Ball play in the hall 10) No inappropriate language 11) Be kind to everyone – All the time. 12) MOST IMPORTANT – HAVE FUN!!!!! *Phone calls can be made with office phone or children can go to staff and use their phone in our office.
Select One
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Spam Capture
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