Student Enrollment Date:
Name:*
Date of Birth:*
 / 
 / 
Age:*
Gender:*
Address:*

PARENT/GUARDIAN INFORMATION:

Parent Name:*
Spouse Name:*
Home Phone:*
-
Cell Phone:*
-
E-mail:*
Place of Employment
Work Phone:*
-
Please Choose:*
Child lives with?*

EMERGENCY CONTACT (other than parent):

Contact Name:*
Contact Address:*
Contact Phone:*
-
SCHOOL INFORMATION:
School Name:*
Grade:*
School District:*

Please answer important health information give details where necessary.

Chronic Health Problems: (Asthma, Diabetes, other; if yes explain) *
Medications: (if yes, please list)*
Allergies: (if yes please list All Food/Medications)*
Personal Physician: (name and phone number)*
Physical Disability: (if yes, give details)*
Psychological Disability: (if yes give details)*

Please read the following statements before signing below:

  1. I hereby certify that my application contains no false information and is complete, truthful, and accurate to the best of my ability.
  2. I authorize medical treatment for my child in the case of emergency; I authorize ambulance or emergency services transportation to doctor or hospital.
  3. I give permission for photographs of my child in class, during trips or events to be used for advertisement and marketing campaigns associated with the after school program.
Your Electronic Signature*