Drop Off Intake Form
Email address *
Email Address *
Your answer
Child's Name *
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
Address *
Your answer
Parent's Name *
Your answer
Phone Number *
Your answer
Secondary Parent or Caregiver *
Your answer
Emergency Contact & Phone Number *
Your answer
WE WILL ONLY RELEASE YOUR CHILD TO INDIVIDUALS LISTED BELOW (PICTURE ID REQUIRED) *
Your answer
DOCTOR'S NAME & Phone Number *
Your answer
DOES YOUR CHILD HAVE ANY KNOWN ALLERGIES? *
If YES DESCRIBE YOUR CHILD'S ALLERGIES (IF AN EIPIPEN IS REQUIRED BRING A PRESCRIPTION FROM YOUR PHYSICIAN) *
Your answer
DOES YOUR CHILD HAVE ANY MEDICAL CONDITIONS WE SHOULD BE AWARE OF? *
If YES DESCRIBE ANY MEDICAL CONDITIONS *
Your answer
Tell us about your child, do they have any likes or dislikes? Anything that can help us get to know them? *
Your answer
Do they have any siblings? If so what are their ages? *
Your answer
Is there anything else you think we should know about your child? *
Your answer
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