EXTENDED PROGRAM REGISTRATION FORM
Official Form-Updated July 19, 2006

Child's Name:   ____________________________________________________________________
                        Last         First           MI                                               Name called

Residence Address:
  _________________________________________________________________

Mailing  Address:
 __________________________________________________________________

Parent's Name(s):
 ___________________________________________________________________

Home Phone _______________ Work Phone________________________

List below the person or persons authorized to pick up your child in case you cannot.

1. __________________________________________________________________
            (Name)                                     (Address)                                     (Phone #)

2. ________________________________________________________________
         (Name)                                                         (Address)                                 (Phone #)

Teacher/Grade
________________________________________________________________

Special interests:
________________________________________________________________

Please check the program desired:
________ Morning only                                  __________ Afternoons only
________ Both A.M. & P.M.                          __________ Drop-ln only

MEDICAL RELEASE

In the event I cannot be reached to make arrangements for emergency medical treatment or illness or injury, I hereby authorize the extended care person or other qualified person in charge to take my child to Dr. ______________ Phone #___________________________ or if not available, to the hospital emergency room.

 Parent's Signature______________________________________

Remarks: Special diet, food  allergies, etc.)

Updated Thursday, December 21, 2006