Child’s Name__________________________________________________

M___F___ Age _____ Birth Date (M/D/Y) __________________________

Height________inches Weight________lbs Eye Color_____________

Address______________________________ Postal Code ______________

Email address__________________________________________________

Is there a custody agreement? Yes _____ No _____ If yes, please explain:

(Photocopy may be required)

_____________________________________________________________

Medical Information

Medical #___________________________________

Doctor__________________________ Phone________________________

Does your child have any physical, mental, emotional or behavioral disabilities of which staff should be aware of? Please explain.

_____________________________________________________________

____________________________________________________

Medication (name, dosage, side effects)

_____________________________________________________________

Medical Alert Information (allergies, etc.)

_________________________________________________________ Immunizations: photocopy provided ___ Conscientious objector signed ___

                                                                                          Parent Information

Name _____________________________Relationship________________ Home Phone _______________________Cell _______________________

Employer __________________________Phone _____________________

Pick up authorization Yes_____ No _____

Name _____________________________Relationship________________

Home Phone _______________________Cell _______________________

Employer _________________________ Phone _____________________

Pick up authorization Yes_____ No _____

                                                                                 Emergency Contacts (different from above)

Name _____________________________Relationship________________ Home Phone _______________________Cell _______________________

Employer __________________________Phone _____________________

Pick up authorization Yes_____ No _____

Name _____________________________Relationship________________

Home Phone _______________________Cell _______________________

Employer _________________________ Phone _____________________

Pick up authorization Yes_____ No _____

Name _____________________________Relationship________________

Home Phone _______________________Cell _______________________

Employer __________________________Phone _____________________

Pick up authorization Yes_____ No _____

***Please provide a list of any person(s) NOT permitted access to your child. Include first and last name.

____________________________________________________________

Guardian Signature____________________________________ Date___________________________