CAPACIDAD Registration Form

CAPACIDAD

Registration Form
Program Start Date

MonthDayYear
Date
Child's Information
Child's Name
Date of Birth

MonthDayYear
Date
Age
Grade
Child's Home Address(es)
Home Phone Number
Primary Language
Identifying Marks
Eye Color
Hair Color
Skin Color
Sex
Gender
Height
Weight
Parent/Guardian Information
Parent/Guardian Name 1
Relationship to Child
Home Address
Cellphone Number
Email
example@example.com
Place of Work
Address
Phone Number
Parent/Guardian Name 2
Relationship to Child
Home Address
Cellphone Number
Email
example@example.com
Place of Work
Address
Phone Number
Healthcare Information
Child's Physician
Address
Phone Number
Allergies/Conditions
If an allergy and/or chronic medical condition exists, please fill out the Individual Healthcare Plan attached.
Dietary notes
Special limitations or concerns
Individual Education Plan (IEP)?
I certify that documentation of physical examination and immunizations in accordance with public school health requirements, and lead poisoning screening in accordance with public health requirements are on file at my child's school.
Initial here
I authorize program staff trained in the basics of first aid and/or CPR to give my child first aid when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and secure necessary medical treatment.
Initial here
Additional Emergency Contacts
Name 1
Relation
Phone #
Release child to?
Name 2
Relation
Phone #
Release child to?
Name 3
Relation
Phone #
Release child to?
Transportation Plan
Program Arrival:

Walk from classroomParent Drop-OffBus/VanOther
Program Departure

Parent Pick-UpUnsupervised Walk (additional permission slip required)Bus/VanOther
I give permission to the following people to pick my child up from the program:

First time pick-ups should bring photo ID. Please provide a copy of any agreement or legal order pertaining to child pick-up.
Name
Phone #
Pick-up conditions

Whenever person shows upOnly when I call ahead of time
Name
Phone #
Pick-up conditions

Whenever person shows upOnly when I call ahead of time
Name
Phone #
Pick-up conditions

Whenever person shows upOnly when I call ahead of time
Name
Phone #
Pick-up conditions

Whenever person shows upOnly when I call ahead of time
Include my child in video, film, or photos of program activities for the purpose of publicity, promotion, fundraising events, educational materials, and warm fuzzy memories.
Initial Here
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

CAPACIDAD

Child's Information

Parent/Guardian Information

Healthcare Information

Additional Emergency Contacts

Transportation Plan