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2023/2024 Emergency form - Before/Aftercare (1 form per child)
Please fill out the Emergency form.
Students will not be admitted into the Before & Aftercare program without completion of this form!
Complete and return form on or prior to the first day your child/children will be participating in this program.
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* Indicates required question
Email
*
Your email
Please provide the name of the child.
*
Please enter full name. (First and Last name)
Your answer
What grade is your child?
*
Choose
PreK 3
PreK 4
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
What class is your child in?
*
Choose
A
B
Please list any known allergies:
*
Your answer
Does your child require to use an Epi Pen?
*
Yes
No
Did you provide an Epi Pen to our school nurse?
*
If your child is not require to use an Epi Pen, please select "No".
Yes
No
Emergency Contact person # 1:
*
Please enter full name. (First and Last name)
Your answer
Emergency Contact person #1:
*
Relation to your child.
Your answer
Emergency Contact person # 1:
*
Please enter phone number. (No dash or space)
Your answer
Emergency Contact person # 1:
*
Please select the type of phone number.
Choose
Cell phone
Work phone
Home phone
Emergency Contact person #1:
*
Please provide an email address.
Your answer
Emergency Contact person #1:
*
This contact person is authorized to pick up the child.
Yes
No
Emergency Contact person # 2:
*
Please enter full name. (First and Last name)
Your answer
Emergency Contact person #2:
*
Relation to your child.
Your answer
Emergency Contact person # 2:
*
Please enter phone number. (No dash or space)
Your answer
Emergency Contact person # 2:
*
Please select the type of phone number.
Choose
Cell phone
Work phone
Home phone
Emergency Contact person # 2:
*
Please provide an email address.
Your answer
Emergency Contact person # 2:
*
This contact person is authorized to pick up the child.
Yes
No
Emergency Contact person # 3:
*
Please enter full name. (First and Last name)
Your answer
Emergency Contact person #3:
*
Relation to your child.
Your answer
Emergency Contact person # 3:
*
Please enter phone number. (No dash or space)
Your answer
Emergency Contact person # 3: Please select the type of phone number.
*
Please select the type of phone number.
Choose
Cell phone
Work phone
Home phone
Emergency Contact person # 3:
*
Please provide an email address.
Your answer
Emergency Contact person # 3:
*
This contact person is authorized to pick up the child.
Yes
No
Please provide your child's Doctor's name.
*
Your answer
Please provide your child's Doctor's phone number.
*
(No dash or space)
Your answer
Please indicate the Hospital of your choice.
*
Your answer
If emergency treatment is required and the parent/guardian cannot be reached immediately, your signature below will empower us to have your child taken to the hospital.
*
Please enter your ful name (First and Last name).
Your answer
I have read all of the below and understand the policies and procedures of the Before/After School Care Program.
*
Yes, I agree.
No (It will result in the child not being allowed in the Before/Aftercare program.)
Please provide your signature for the agreement above.
*
Please enter your full name (First and Last name).
Your answer
A copy of your responses will be emailed to the address you provided.
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