Child's full name

Birthdate

Program enrolling: Extended Care:
   Before School After School School Closing Days

Program enrolling: Kindergarten Wrap:
   A.M. Enrichment P.M. Enrichment School Closing Days
   (if needing extended care for Kindergarten, please check all that apply above)

Starting date

Days and hours he/she will attend

Home address

Mother's name

Father's name

Child lives with:
both parents
one parent (please specify)
shared custody (please describe arrangements)
other (please describe)

Who will typically drop off your child?

Who will typically pick up your child?

Who else is authorized to pick up your child?

Is anyone NOT authorized to pick up your child?

Phone Number

E-mail

Will your child be riding a bus? yes no     Bus #

If your child misses his/her bus, who would be the contact person to call to inform that your child is to be picked up at Extended Care?
Name

Relationship

Phone Number

HEALTH

Are there any special health needs that we should be aware of?

Any known allergies? Please list.

Any frequent/ongoing medicine prescriptions?

SOCIAL RELATIONSHIPS

Please list siblings and ages

What special benefits would you like for your child to gain from his/her experience at the Extended Care and Kindergarten Wrap Program?

Is there any other information about your child that you'd like to share with us?