Before & After Care v1.jpg
Student & Family Information
Student’s Name, (Last, First, MI) *
Student’s Name, (Last, First, MI)
Student’s Name, (Last, First, MI)
Student’s Name, (Last, First, MI)
Student’s Name, (Last, First, MI)
Student’s Name, (Last, First, MI)
Student’s Name, (Last, First, MI)
Student’s Name, (Last, First, MI)
Parent/Guardian Name(s):
Parent/Guardian Name(s):
Address *
Address
Phone *
Phone
Dietary Restrictions:
Please list any dietary restrictions your child(ren) have:
Allergies
Please list any allergies your child(ren) have:
Medical Conditions
Please list any medical conditions your child(ren) have:
Please list adult persons authorized to pick up your child(ren)
Authorized Adult 1 *
Authorized Adult 1
Phone *
Phone
Authorized Adult 2 *
Authorized Adult 2
Phone *
Phone
Authorized Adult 3
Authorized Adult 3
Phone *
Phone
Emergency Contact Information
Emergency Contact *
Emergency Contact
Phone *
Phone
Emergency Contact 2 *
Emergency Contact 2
Phone *
Phone