Aftercare Registration Form

Millbury Public Schools After-Care Program Registration Form

 

 

Name of Child__________________________________Date of Birth___________

 

Child attends: Elmwood Street School______Grade____________

                       Shaw Elementary School_____Grade___________

 

 

Address____________________________________Telephone___________

             ____________________________________

 

 

Name(s) Parent(s)_________________________________________________

 

 

 

Days of enrollment:   _____ M  _____Tu  _____W  _____Th  _____F

 

 

 

$10.00 Registration Fee (non refundable):    _____ Paid      _____ Not Paid

 

 

 

Signature___________________________

 

Date_______________________________

 

 

Please inform the school your child will be attending the Millbury

After-Care Program and which days.

 

 

Parent/Guardian________________________________Phone(h)______________

 

Address__________________________________Phone(c)______________

 

Work Place________________________________Phone(w)______________

 

Work Address______________________________________________

 

 

 

Parent/Guardian________________________________Phone(h)______________

 

Address__________________________________Phone(c)______________

 

Work Place________________________________Phone(w)______________

 

Work Address______________________________________________

 

 

 

 

Signature________________________________Date___________

 

Signature________________________________Date___________

 

 

 

 

 

Child’s Information Form

Child’s Name________________________ Date of Birth______________

Address______________________________________________________

Telephone__________________

 

Is there documentation for a physical exam and immunization record at your child’s school? Yes_______ No_______

List any special limitation or concerns your child may have:

 

   

List any special interests your child may have:

                                                                                                                    

 

 

 Identifying information:

eye color___________      height______________      sex_______________

hair color____________    weight_____________       race_______________

other_____________

 

 Signature___________________________________ Date_____________ 

First Aid and Emergency Care

Child’s Name____________________________ Date of Birth__________

I understand that there is a nurse available and I give them my permission to treat my child if needed.

I understand I will be contacted immediately in the event of an emergency, however, if I am unable to be reached, I give permission for the Millbury After-Care Program to contact the following persons:

Name_________________________________ Phone (h)____________________

Relationship to the child____________________Phone (w)_______________

                                                                   Phone(c)__________________

Name_________________________________ Phone (h)____________________

Relationship to the child____________________ Phone (w)_______________

                                                                   Phone(c)__________________

I herby authorize the program to transport via ambulance to

___________________________________ and or nearest hospital.

 

Childs Allergies_______________________________________________

Chronic Health Conditions_____________________________________ 

 

Signature_____________________________________ Date____________

 

Authorized Pick Up

I give permission for the following adults to pick up my child from the Millbury After-Care Program.

Name__________________________________Phone (h)________________ Relationship to child________________________Phone (w)____________                                                                               Phone(c)_________________      

Name__________________________________Phone (h)_________________ Relationship to child________________________Phone (w)____________                                                                                Phone(c)__________________

Name__________________________________Phone (h)_________________ Relationship to child________________________Phone (w)_____________                                                                   Phone(c)___________________

Please note:  to ensure the safety of your child the adults you list as an authorized pick-up will be asked to produce a photo ID before we can release your child to them.

 

Security Code      

 

The security code is to ensure the safety of your child. If a situation occurs when you are unable to pick your child from the program and you need someone that is not on the Authorized Pick Up list, please follow the following procedure:

1) Call the site where your child is enrolled.

2) Be certain to speak with the Site Supervisor.

3) Inform the Site Supervisor of the person you authorize to pick up your          child on that given day.

4) The Site Supervisor will ask you for your security code (listed below) for identification purposes.

Note: We will not release your child to persons not listed above unless you call and provide the security code.  

Security Code_______________________________________

Signature____________________________________________Date______________

 

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