ALDERSGATE PLAYSCHOOL
SUMMER REGISTRATION FORM/EMERGENCY INFORMATION
2013
Child's
full name __________________________________________________
Child's birth date _____________________________________
Parent's
Name(s) __________________________________________________
Mailing
Address ________________________________ zip code __________
Street
Address (if different from mailing)_____________________________
Home
telephone ____________________ Cell
Phone ____________________
E-mail
address ____________________________ Beeper ________________
Father's
Employment ____________________________Phone ___________
Mother's
Employment ____________________________Phone ____________
EMERGENCY NUMBERS AND CONTACTS
Name
_______________________ Name
___________________________
Relationship
____________________
Relationship______________________
Telephone
______________________ Telephone
________________________
LIST KNOWN ALLERGIES
___________________________________________
In the
event of an emergency all attempts will be made to contact given emergency
numbers. If parents cannot be reached
and medical treatment seems to be necessary, authorization is given to obtain
treatment.
PARENT SIGNATURE
__________________________________________
CHILD PHYSICIAN/PHONE
NUMBER___________________________
When I register my child for
the summer program, I understand that a registration/insurance fee of $25.00
will accompany this form. This $25.00 is
non-refundable.
DAYS DESIRED:______MON;_____TUES;_____WED;______THURS;
(OTHER SIDE<
PLEASE)
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