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After School Enrichment Identification and Emergency Form

Please complete the form below. Required fields marked with an asterisk *

Identification and Emergency Information

Answer Required

Student Information

First Name*

Answer Required

Middle Name

Answer Required

Last Name*

Answer Required

Gender *

Answer Required

Male

Female

Date of Birth*

Answer Required

Known Allergies*

Answer Required

Parent/Guardian #1 Information

First Name*

Answer Required

Last Name*

Answer Required

Mobile Phone*

Number Required

Work Phone*

Number Required

Parent/Guardian #2 Information

First Name

Answer Required

Last Name

Answer Required

Mobile Phone*

Number Required

Work Phone*

Number Required

Children will not be allowed to leave with any other person without authorization from main parent/guardian. The person picking up the child with have to show proper identification. If there are added persons who is not on the orignal form given - the parent/guardian will recieve a phone call confirming the change/add.

Please List the Persons Authorized to Take Your Child From The Facility

Name, Phone Number, Relationship to Student

Answer Required

Please List Additional Persons Who May Be Called in an Emergency:

Name, Telephone Number, Relationship to Student

Answer Required