STRICKLAND EXTENDED CARE ENROLLMENT FORM
Hours of Operation: Monday - Friday 3p.m. - 6p.m.
(512) 447-1777
Child's Name:
Date of Admission:
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Month
-
Day
Year
Date
Child's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Home Phone:
Format: (000) 000-0000.
Child's Age:
Date of Birth:
-
Month
-
Day
Year
Date
Parent's or Guardian's name:
Address (if different from above):
Days and Times of Attendance:
Phone numbers while child is in care of:
Mother's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Phone Number:
Guardian's Phone Number:
Name to call in an emergency (if parents cannot be reached):
Relationship:
Address:
Phone:
Format: (000) 000-0000.
List any special concerns or needs your child may have, such as, allergies, existing illness, previous serious illness, injuries during the past 12 months, any medication prescribed for long-term continuous use, and any other information which staff should be aware of:
CONSENTS:
I give consent for this facility to secure any and all necessary emergency medical care for my child:
Signature of Parent or Legal Guardian
Date
-
Month
-
Day
Year
Date
My child's immunization records are on file at Strickland Christian School and I acknowledge receipt of "A Parent's Guide to Day Care" and "Parent's Rights".
Signature of Parent or Legal Guardian
Date
-
Month
-
Day
Year
Date
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