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Date of Application (MM/DD/YY) Start Date (MM/DD/YY)
Program

Student's Name

Street Address
City State Zip Code
Sex Male Female Birth date (MM/DD/YY)

Parent / Guardian Information
Mother's Name Occupation

Home Phone

Mobile Phone
Home Address
City State Zip Code
Company Work Phone
Work Address
City State Zip Code
Father's Name Occupation

Home Phone

Mobile Phone
Home Address
City State Zip Code
Company Work Phone
Work Address
City State Zip Code

Pickup Authorization
1. Name Phone

Relationship

Home Address

City State Zip Code

2. Name Phone

Relationship

Home Address

City State Zip Code


Emergency Contacts
1. Name Phone

Relationship

Home Address

City State Zip Code

2. Name Phone

Relationship

Home Address

City State Zip Code

Name of Person UNAUTHORIZED to pick-up the child
If a non-custodial parent is not included among those persons authorized by the custodial parent to pick up the child, please attach a copy of the appropriate court orders.


Medical Information
Physician Name Phone

Address

City State Zip Code

Hospital Affiliation

Insurance Company Policy Number

Child's Allergies

Food
Medication
Other
 
Important information our school should know your child

I UNDERSTAND THAT I NEED TO PICK UP MY CHILD ON OR BEFORE 6:30PM FOR FULL DAY PROGRAM AND ON OR BEFORE 3:00PM FOR HALF DAY PROGRAM, OTHERWISE THERE WILL BE A LATE FEE CHARGED TO ME BASED ON THE CENTER POLICY.

PARENT SIGNATURE: ______________________________________________________
DATE: ________________________________________

 

PLEASE NOTIFY OUR DIRECTOR IMMEDIATELY IF ANY OF THE ABOVE INFORMATION CHANGES. THANK YOU!

Print Form Last Updated: February 25, 2007
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