Before School Care Emergency Form
Please complete online BSC emergency form. Any questions email ksilber@dist113.org
Thanks, Kate Silber
Email address *
Student Name *
Your answer
Please indicate consistency in days of attendance: *
Mother/Guardian Name: *
Your answer
Mother/Guardian Email *
Your answer
Mother/Guardian Phone Number (home, work, and cell) *
Your answer
Father/Guardian Name *
Your answer
Father/Guardian Email *
Your answer
Father/Guardian Phone Number (home, work, and cell)
Your answer
Name & Address of Parent Responsible for Payment: *
Your answer
AUTHORIZED EMERGENCY CONTACT (Name, Phone number, and relationship) *
Your answer
AUTHORIZED EMERGENCY CONTACT (Name, Phone number, and relationship) *
Your answer
AUTHORIZED EMERGENCY CONTACT (Name, Phone number, and relationship) *
Your answer
Doctor's Name and Phone *
Your answer
Allergies *
Your answer
Special Needs *
Your answer
PLAYGROUND AUTHORIZATION: By writing your name below you authorize that your child has permission to leave the Supervision of the Before Care Program to play outside when the playground Supervisors are present. *
Your answer
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