Parents' Day Out Registration Form

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Home Address

Street Address Line 2

CityState

Zip
Home Phone
Format: (000) 000-0000.
E Mail
example@example.com
Mother's Name
Home Phone
Format: (000) 000-0000.
Cell
Father's Name
Home Phone
Format: (000) 000-0000.
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
Format: (000) 000-0000.
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:
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 AHS-ECE or Educators Rising program in accordance with the conditions set forth above.
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 or club's webpage on the Aiken High School website, AHS social media, and in ECE promotional materials for Aiken County Public School District. 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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 meal/snack that are not licensed by DSS.
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Children
Should be Empty:

AHS Early Childhood Education (ECE) Program - Childcare Services Registration Form