CHILD'S INFORMATION
Last Name

First Name

Gender

Date of Birth

School Meal Plan

Allergies or other important information

I give permission for my child to be photographed in connection with the school.
AgreeDisagree
I give permission for my child to participate in walking trips around the neighborhood.
AgreeDisagree


PARENT/GUARDIAN 1 INFORMATION

Last Name
First Name
Email Address
Home Address
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
Employer
Address
City
State
Zip Code
PARENT/GUARDIAN 2 INFORMATION

Last Name
First Name
Email Address
Home Address
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
Employer
Address
City
State
Zip Code

CUSTODIAL INFORMATION:
If a non-custodial parent is not among those persons authorized to pick up the child, a court order must be provided. Please select the appropriate box below.


EMERGENCY CONTACTS/AUTHORIZED PICK-UPS:

1. Name
Address
Cell Phone
Relation to Child
2. Name
Address
Cell Phone
Relation to Child
3. Name
Address
Cell Phone
Relation to Child