After School Enrichment Identification and Emergency Form Please complete the form below. Required fields marked with an asterisk * After School Enrichment Identification and Emergency Form Identification and Emergency InformationStudent InformationFirst Name*Middle NameLast Name*Gender*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Known Allergies*Parent/Guardian #1 InformationFirst Name*Last Name*Mobile Phone*Work Phone*Parent/Guardian #2 InformationFirst NameLast NameMobile Phone*Work Phone*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 FacilityPlease List Additional Persons Who May Be Called in an Emergency:CAPTCHA