• Image field 218
  • Child's Information

  • NOTE - Children need to have completed Kindergarten before they are eligible to participate in the Boys & Girls Mobile Club. 

  • Parents' Information

    Parent/Guardian 1
  • Format: (000) 000-0000.
  • Parent/Guardian 2
  • Format: (000) 000-0000.
  • Emergency Contacts/Authorized Pickup

    Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
  • Emergency Contact #1

  • Format: (000) 000-0000.
  • Emergency Contact #2

  • Format: (000) 000-0000.
  • Medical / Health Information

  • Format: (000) 000-0000.
  • Does your child have any food, medication or environmental allergies?*
  • Allergies? Check all that apply*
  • 0/150
  • Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?*
  • Does your child have a special health or medical condition?*
  • 0/150
  • Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours?*
  • 0/150
  • Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?*
  • 0/150
  • Statement of Understanding

  • Acknowledgement of Policies and Procedures I have reviewed and received a copy of the center's policies and procedures/handbook.*
  • Date Signed*
     - -
  • Should be Empty: