After School Program Updated Registration

1st Child's Name *

1st Child's Name

First Name

Last Name

School your child attends *

Birthdate *

Birthdate

MM

DD

YYYY

Gender *

Second Child's Name

Second Child's Name

First Name

Last Name

School your child attends

Gender

PARENT OR GUARDIAN INFORMATION

Primary Contact Name *

Primary Contact Name

First Name

Last Name

Phone Numbers (Home, Cell) *

Email Address *

Home Address *

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Name *

Work Phone Number *

Work Phone Number

(###)

###

####

Emergency contact person *

Emergency contact phone *

Emergency contact phone

(###)

###

####

Authorized Pickup Names *

EMERGENCY MEDICAL INFORMATION

Child's Physician *

Physician's Address *

Physician's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physician's Phone *

Physician's Phone

(###)

###

####

Allergy Information *

Date of last Tetanus *

Date of last Tetanus

MM

DD

YYYY

Child's Dentist *

Preferred Hospital *

Health Insurance Company *

Health Insurance Company Phone Number *

Health Insurance Company Phone Number

(###)

###

####

Parent or Legal Guardians Signature *