Main Registration part 1

Child/Parent/Guardian Information
Child's Name
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Birth Day //
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Age
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Sex
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School
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Grade
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Address
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E-mail
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This is required because this is our primary form of communication when not in session.
Parent or Guardian Name - Mom
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Phone -- ext
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Employer Name and Address
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Parent or Guardian Name - Dad
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Phone -- ext
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Employer Name and Address
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Emergency Contacts
Emergencies may necessitate contact with designated individuals who can assume responsibility for the welfare of your child when you are available. Please review this form and carefully choose people who you feel should be called in an extreme emergency when you cannot be reached. You must provide the names and phone numbers of three people. It is imperative that your selection is based on several criteria: 1. Be sure that individuals are in close proximity to the Study Hall and are responsible individuals who your child trusts. 2. Notify these individuals that you have designated them to serve in this capacity on this form. For our program, please provide three (3) names and full addresses other than parents/guardians:
Contact 1
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Contact 1 Phone -- ext
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Contact 2
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Contact 2 Phone -- ext
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Contact 3
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Contact 3 Phone -- ext
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Medical Information
Please provide information on Hospital choice, allergies, any physical limitations and Doctor information
Hospital Choices
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Consent and Agreement for Emergencies
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I also authorize the Director or Director Designee to contact my child’s health care provider to alert him/her to my child’s situation. I understand that I will be responsible for all charges not covered by insurance. I give consent for the emergency contact person listed on Emergency Form Part I to act on my behalf until I am available. I agree to review and update this information whenever a change occurs and at least every six (6) months.
Allergy/Medical Information
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Food, Drug, Beverages, Insects and Vegetation.
Activities
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Doctor Name
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Doctor Address
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Insurance Carrier and Policy #
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Main Registration part 2
Please go to Registration Forms to print out Main Registration Online part 2 and bring in with you or pick up copy at the Study Hall.
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