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Child’s Full Name

Sex

Age

Date of Birth

Home Phone Number

Street Address

City

State/Province

ZIP / Postal Code

Father's Full Name

Home Phone Number

Father’s Home Address (if different from child’s)

City

State/Province

ZIP / Postal Code

Father’s Place of Employment

Work Phone Number

Employer’s Street Address

City

State/Province

ZIP / Postal Code

Mother's Full Name

Home Phone Number

Mother’s Home Address (if different from child’s)

City

State/Province

ZIP / Postal Code

Mother’s Place of Employment

Work Phone Number

Employer’s Street Address

City

State/Province

ZIP / Postal Code

Child’s Living ArrangementsBoth ParentsMotherFatherOther

Child’s Legal Guardian(s)Both ParentsMotherFatherOther

The child may be released to the person(s) signing this agreement or to the following:

Name

Street Address

City

State/Province

ZIP / Postal Code

Telephone Number

Relationship to child

Relationship to Parent(s) or Guardian

Other identifying information (if any)

Persons to contact in the case of emergency when parent or guardian cannot be reached

Name

Telephone Number

Name

Telephone Number

Name

Telephone Number

Child’s Doctor or Clinic Name

Doctor/Clinic Phone Number

My child has the following special needs

The following special accommodation(s) may be required to most effectively meet my child’s needs while at the center

My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre- existing illness, allergies, or health concerns

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