Request edit access
After Care Registration Form
2017 - 2018 AFTER CARE REGISTRATION FORM
Email address
Student's Name (last, first)
Your answer
Class:
Address:
Your answer
Home Phone:
Your answer
Cell Phone:
Your answer
Email Address
Your answer
Additional Contact 1: (name, telephone, relationship)
Your answer
Additional Contact 2: (name, telephone, relationship)
Your answer
What would you like the After Care staff to do in the event of an emergency?
Your answer
Program Schedule:
Required
Is there ever a day that your child may take the bus home from school?
Required
If you answered yes, please give the day(s) of the week or a brief explanation.
Your answer
Does your child have an allergy?
Required
If yes, please indicate allergies.
Your answer
Does your child's allergy require an Epi Pen to be administered?
Required
Will you be supplying After Care with an EpiPen?(separate from the one provided for the normal school day)
Required
Are there any specific medical conditions or issues of concern?
Required
If yes, please explain briefly.
Your answer
The following people are given permission to pick up my child/children from After Care: (Please list anyone who has permission to pick up your child. ID may be requested at pick up.)
Your answer
The following people are not permitted to pick up my child/children from After Care:
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Church of St. Clare. Report Abuse - Terms of Service - Additional Terms