Child's Name: _____________________________
Address: _________________________________
              _________________________________

DOB________Age_______    Home Phone #____________________
                                              Work Phone #____________________

Parent / Guardians:  Mother_____________________________________
                               Father_____________________________________

Place of Employment:  Mother____________________________________
                                 Father_____________________________________

Emergency Contact: _____________________________________

Allergies or Illnesses: ___________________________________

Other Pertinent Information_______________________________

 In case of an emergency, I authorize the Before School Program Staff to obtain medical assistance for my child in the event I cannot be contacted immediately.

________________________ ______________________

Parent Signature ___________________________________Date_____________________

Please mail your application with registration fees to: