Grizzly Den Application
Please complete one for EACH child. Also, please list stepparents under the emergency contacts.

Should you have any questions

Child's Name *
Last Name, First Name MiddleI nitial
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Mother Information
Mother's Name *
Your answer
Mother's Home Phone Number *
Your answer
Mother's Cell Phone Number *
Your answer
Mother's Home Address *
Your answer
Mother's Place of Employment *
Your answer
Mother's Work Phone Number *
Your answer
Mother's Email Address
Your answer
Father Information
If any information (i.e.: address, phone number, etc) are the same as the mother, please put 'Same As Above'.
Father's Name *
Your answer
Father's Home Phone Number *
Your answer
Father's Cell Phone Number *
Your answer
Father's Home Address *
Your answer
Father's Place of Employment *
Your answer
Father's Work Phone Number *
Your answer
Father's Email Address
Your answer
Custody and Attendance
Does the child live with both parents or guardians listed above? *
When will your child be attending the Grizzly Den? *
Required
Are there any restrictions on anyone's access or visitation with your child (i.e.: ex-spouse)? If so, please explain below.
Your answer
Emergency Contacts
In case of an emergency, if we cannot reach either parent, whom should we contact next?

While you can add up to five separate emergency contacts, only one contact is required.

Contact #1 - Name *
Your answer
Contact #1 - Relationship to Child *
Your answer
Contact #1 - Cell, Home, and/or Work Phone Number *
Please specify what each number is (i.e.: Home - xxx-xxx-xxxx; cell - xxx-xxx-xxxx)
Your answer
Contact #2 - Name
Your answer
Contact #2 - Relationship to Child
Your answer
Contact #2 - Cell, Home, and/or Work Phone Number
Please specify what each number is (i.e.: Home - xxx-xxx-xxxx; cell - xxx-xxx-xxxx)
Your answer
Contact #3 - Name
Your answer
Contact #3 - Relationship to Child
Your answer
Contact #3 - Cell, Home, and/or Work Phone Number
Please specify what each number is (i.e.: Home - xxx-xxx-xxxx; cell - xxx-xxx-xxxx)
Your answer
Contact #4 - Name
Your answer
Contact #4 - Relationship to Child
Your answer
Contact #4 - Cell, Home, and/or Work Phone Number
Please specify what each number is (i.e.: Home - xxx-xxx-xxxx; cell - xxx-xxx-xxxx)
Your answer
Contact #5 - Name
Your answer
Contact #5 - Relationship to Child
Your answer
Contact #5 - Cell, Home, and/or Work Phone Number
Please specify what each number is (i.e.: Home - xxx-xxx-xxxx; cell - xxx-xxx-xxxx)
Your answer
Do all of the emergency contacts have permission to pick up your child?
Medical Information
Child's Doctor *
Your answer
Doctor's Phone Number
Your answer
Child's Dentist
Your answer
Dentist's Phone Number
Your answer
Please list any allergies. *
If not applicable, please type N/A.
Your answer
Does your child have any medical condition which requires speical attention? If so, please explain. *
If not applicable, please type N/A.
Your answer
Clinic, Facility, or Hospital Preference *
Required
Billing and Payments
If you would prefer contact (i.e.: balance sheets, letters, etc. from the Grizzly Den) via email, please provide your emial address.
Your answer
Understanding the Grizzly Den Policies
By marking 'Yes' below, I understand that the Grizzly Den is only open when school is in session. *
By marking 'Yes' below, I understand that DROP-IN payments are due no later than the time of pick up, but all fees may be paid in advance. *
By marking 'Yes' below, I understand that (for DROP-IN) I must call the office in advance (by noon on the day(s) your child needs to stay in the afternoon Grizzly Den or by noon the day before your child needs to stay in the morning Grizzly Den). Failure to notify the office will result in your child not being able to attend the Grizzly Den. *
By marking 'Yes' below, I understand the afternoon Grizzly Den ends at 6 pm. If I am late a $1 per minute per child feel will be accessed. In the event that mychild is not picked up by 6:15 pm, the proper authorities will be notified that the child has been abandoned. *
By marking 'Yes' below, I understand the morning Grizzly Den begins at 6 am. Supervision is not supplied prior to 6 am. *
By marking 'Yes' below, I understand that EVERY DAY stay payments are due on the first day of the week or in advance. I also understand that the weekly rate is due even if my child does not attend the Grizzly Den (unless otherwise approved by the director). This does not apply to school closings. *
By marking 'Yes' below, I understand the late payment fee is $5 per day per child. This fee will begin after non-payment for five school/business days. After an additional five school/business days of non-payment, my child will not be able to attend the Grizzly Den. *
By marking 'Yes' below, I understand that (-in the event a medical emergency occurs and I cannot be reached) I authorize the person in charge to transport my child to the nearest medical clinic, facility, or hospital. *
By marking 'Yes' below, I have received and read the Grizzly Den brochure explaining the policies, payment schedules, and other information for the program. I agree to the terms, schedule, and additional information listed above and in the brochure. *
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