Ezion Fair Christian Community Academy (Centers Need to Know)

Ezion Fair Christian Community Academy
1400 B Street Wilmington, Delaware 19801 *Ph: 302.652.9114 * Fax: 302.652.7071 www.ezionfairacademy.org
"CENTER'S NEED TO KNOW INFORMATION CHECKLIST
(Please print clearly and respond to all fields)
CHILD'S FULL NAME
CHILD'S DAYCARE HOURS
DOES THE CHILD HAVE AN IEP? If yes please provide
PARENTS EMPLOYMENT
WORK HOURS
EMERGENCY #1
FULL NAME & RELATIONSHIP
EMERGENCY #2
FULL NAME & RELATIONSHIP
PHONE NUMBER
DOCTOR'S NAME
DOCTOR'S ADDRESS
DOCTOR'S PHONE
MY CHILD CAN BE RELEASED TO: (Name, Relationship, Telephone Number)
1
Name and Relationship
Phone Number
Please enter a valid phone number.
2
Name and Relationship
Phone Number
Please enter a valid phone number.
3
Name and Relationship
Phone Number
Please enter a valid phone number.
4
Name and Relationship
Phone Number
Please enter a valid phone number.
5
Name and Relationship
Phone Number
Please enter a valid phone number.
6
Phone Number
Please enter a valid phone number.
PARENT SIGNATURE

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DATE

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Date
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Ezion Fair Christian Community Academy