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Our Lady of Lourdes After Care School Program 2019-2020
Please Note: The fee will be $12 a day for Aftercare.
After Care Child Registration Form
MELISA DENSFORD, After Care Director: 513-604-2102 or (513) 347-2660 ext. 3024.
Please complete a Registration Form for each child.
Childs Name *
Your answer
Nickname:
Your answer
Age: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Gender: *
Required
Address: *
Your answer
Home Telephone: *
Your answer
Physician's Name and Telephone: *
Your answer
Food/Medication Allergies: *
Your answer
Please check the days your child will attend: *
Required
Is there anything else we should know about to ensure the safety and well being of your child? Medical conditions, likes, dislikes, etc: *
Your answer
Please list ALL people (other than yourself) who are authorized to pick up your child.
Name, Telephone, Relationship: *
Your answer
EMERGENCY CONTACT INFORMATION
Mother's Name: *
Your answer
Work Number
Your answer
Company Name
Your answer
Cell/Pager Number *
Your answer
Father's Name *
Your answer
Work Number
Your answer
Company Name
Your answer
Cell/Pager Number *
Your answer
In the unlikely event we cannot reach you in an emergency, please provide the name and telephone number of a relative or friend we should contact. We will, of course, continue to make all reasonable attempts to reach you.
Name, Relationship to Child, Best Contact Number *
Your answer
Name, Relationship to Child, Best Contact Number
Your answer
Please submit the $25 Registration Fee to the school office upon completion of this form. Attn: Melisa Densford. Any questions or concerns, please contact: Melisa Densford at (513) 604-2102 or (513) 347-2660 ext. 3024.
By checking the box below you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge and agreeing to the terms and conditions of Our Lady of Lourdes After Care Program. *
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