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Emergency Contact
Please complete the following to accompany summer program registration.
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Child's Name and Date of Birth
Your answer
Please list 3-4 emergency contacts (Name, Relationship and Phone Number) in the order that we should call. Please include one out-of-town contact.
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Primary Physician Name
Your answer
Physician Office Phone
Your answer
Physician's Physical Address (Street, City, State, Zip Code)
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Does your child have any allergies?
No
Yes
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If yes, please explain.
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Does your child have any medical conditions?
Yes
No
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If yes, please explain.
Your answer
Is your child taking any medications regularly?
Yes
No
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If your child requires medicine to be administered during the regular school day, please request a Medication Administration Form from the office.
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