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
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