Knollwood Christian Academy After School Care Registration

Knollwood Christian Academy After School Care Registration
Child's Full Name:
Child goes by what name
Address
City
State
Zip Code
Home Phone
Date of Birth

MonthDayYear
Date
Grade/Teacher
Parents or Guardian Information:
Birth Fathers Name
Address
City
State
Zip Code
Home Phone
Fathers Employer
Work Phone
Pager
Birth Mothers Name
Address
City
State
Zip Code
Home Phone
Mothers Employer
Work Phone
Pager
In case of emergency & parents can't be contacted, who may be contacted locally?
Name
Relationship to child
Phone
Name
Relationship to child
Phone
Child may be released to the following without permission from the parent or guardian:
Name
Phone
Name
Phone
Name
Phone
Parents' Marital Status: if divorced, need divorce papers ***
Are you Single, Married, Separated, or Divorced:
Step-Parent/ Guardians Name
Work Phone
Cell Phone
Medical Information:
Childs Doctor
Phone
Does your child have any allergies
Is your child on any medication
Does your child require any special needs
Parent Signature
Date

MonthDayYear
Date
Should be Empty: