Extended Care Enrollment Form

Child’s Name:_________________________ Birthdate: __________

Address: _____________________________ Phone: ____________

Parent/Guardian Name: ___________________________________

Father’s Employer: _______________________________________

Work Phone: _____________________ Cell: __________________

Mother’s Employer: _______________________________________

Work Phone: _____________________ Cell: __________________

Persons authorized to pick up your child/children:

___________________________ Phone: _________ Cell: ________

___________________________ Phone: _________ Cell: ________

___________________________ Phone: _________ Cell: ________

Who may NOT pick up your child? ___________________________

_______________________________________________________

Emergency Numbers if authorized persons cannot be reached:

Name: _______________________________ Phone: ___________

Name: _______________________________ Phone: ___________

Emergency Care:

Agents of the Extended Care Program have my permission to obtain emergency

medical attention for my child. You should be aware of the following special

circumstances regarding my child: (Please list drug & food allergies and other

medical information).

_______________________________________________________

_______________________________________________________

Child’s Doctor: _________________________ Phone: ___________

Parent’s Signature: _____________________ Date: _____________