Family First Center of Lake County Registration Form

Family Information
Name of Parent

First Name Last Name
Please check this box if deceased

deceased
Occupation
Work Phone Number
Please enter a valid phone number.
Address (if not same as above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name of Parent

First Name Last Name
Please check this box if deceased

deceased
Occupation
Work Phone Number
Please enter a valid phone number.
Address (if not same as above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Siblings
Student Lives With

Both Parents Mother Father Appointed Legal Guardian (neither parents)
Name of Legal Guardian

First Name Last Name
Occupation
Work Phone Number
Please enter a valid phone number.
Address (if not same as above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Medical and Health Information
Is your child taking any medications at home or at school?

Yes No
Please provide details
Does your Child have any allergies to any of the following: Insect Bites, Food, Seasonal Allergies, Latex, Medicine, etc.

Yes No
Please provide details

Acknowledgement, Authorization, and Consent
By signing this form, I hereby authorize the school to use the information herein provided for the processing of my child's application. I understand that the information shared herein shall be for the purpose of the admission of my child. I authorize and provide consent to the school in releasing my child's medical and health information with the school's health services. In the event that my child becomes ill, sustains an injury, or in any case, needs immediate medical care during under the care and supervision of the school, I hereby authorize the school to administer first aid for my child's relief. In the event that my child needs immediate attention and it is not practical to wait for receiving instructions from the parents or appointed legal guardian or the child, I, as a parent/legal guardian, hereby authorize the school, its staff, to act as agents in delivering my child to a hospital and performing decisions necessary as recommended by an attending physician for the care of my child such as conducting X-ray, anesthetic, and other medical treatments such as surgery. I further declare that the information I have provided in this form is true and correct to the best of my knowledge.
Signature of Parent/Guardian

Clear
Name

First Name Last Name
Date

Month Day Year
Date

Family First Center of Lake County