Parent / Guardian Name(s)*
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Cell Number*( ) -
Secondary Phone Number( ) -
Email Address*
Text
Email
Phone Call
Emergency Contacts (in the event we are not able to reach you):
Emergency Contact #1*
Emergency Contact #1 Phone Number*( ) -
Relationship to Child*
Emergency Contact #2
Emergency Contact #2 Phone( ) -
Relationship to Child
Permission To Check-In / Check-Out - in addition to parents. (Must be at least 16 years old.)
1.
2.
Yes
No
Parent / Guardian Signature (to be signed at check-in)
Signature Date
Child #1
Male
Female
Birth Date January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000
Grade as of September 2023
School
Allergies
Special Needs or Concerns
Child #2
Child #3
Child #4
