Parents' Night Out Registration Form

AHS Early Childhood Education (ECE) Program - Childcare Services Registration Form
Child's Full Name*
Sex/Gender*
Date of Birth*

MonthDayYear
Date
Address*

Home Address

Street Address Line 2

CityState

Zip
Home Phone*
E Mail*
example@example.com
Mother's Name*
Home Phone
Cell*
Father's Name*
Home Phone
Cell*
The child may be released to the person(s) signing this agreement or to the following:
Name
Relationship to Parent
Address

Address

Street Address Line 2

CityState

Zip
Home Number
Cell Number
Other Info
Name
Relationship to Parent
Address

Address

Street Address Line 2

CityState

Zip
Home Number
Cell Number
Other Info
Persons to contact in case of emergency when parent or guardian cannot be reached:
Name*
Cell Number*
Name*
Cell Number*
Child's Doctor or Clinic Name*
Phone Number*
Insurance Provider*
Policy Number*
Choice of Hospital*
My child has the following special needs
The following accommodations may be required to most effectively meet my child's needs while at school
My child is currently on medication(s) prescribed for long-term continuous use and/or has the following e-existing illness, allergies (especially food related), or health concerns:
EMERGENCY MEDICAL AUTHORIZATION
The AHS ECE program does not provide Accident/Medical Insurance for program participants. I authorize the Aiken High School ECE instructor to provide emergency treatment in the event I cannot be contacted. I recognize that participation in AHS ECE activities may expose my child to some risk of injury. I agree to hold the Aiken High School, the ECE program, and its instructor harmless from any claims for damage to any property or persons which may occur through participation in AHS ECE childcare services.
I have read and understand the above information. My child has permission to participate in this FCCLA program in accordance with the conditions set forth above.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
I hereby give the ECE program of Aiken High permission to post photographs taken of my child during the AHS ECE childcare services on the class's webpage on the Aiken High School website and in ECE promotional materials at Aiken High School. I hereby certify that I am the parent or guardian for the person named above. I do give consent according to the terms listed above without reservations to the foregoing on behalf of him, her, or them.
Printed Name of Parent or Guardian*
Signature of Parent or Guardian*

Clear
Date*

MonthDayYear
Date
1) My child will not be allowed to enter or leave the facility without being escorted by the parent or person authorized by the parent. 2) The ECE instructor agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to materials used, etc. which include my child. 3) I understand that the ECE students and instructor are providing child care and a snack that are not licensed by DSS.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

EMERGENCY MEDICAL AUTHORIZATION