SAINT MICHAEL
SCHOOL
21 Sixth Street, Lowell, MA
01850
EXTENDED DAY
CARE PROGRAM
Registration
Form
2011 – 2012
DATE: Grade/Teacher: ______
Child’s Name: ______
Address: City/Town:
Telephone: Zip
Code:
Date of Birth: Place
of Birth: ______
Father’s Name: ______
Address:
(if different from child)
Telephone: (Home) (Work)
Mother’s Name: (Maiden Name): ____________
Address:
(if different from child)
Telephone: (Home) (Work)
Is your child in the custody of both
parents? YES NO If not,
Legal Guardian Name: Relationship: ______
(only if
someone other than parents)
Address:
(if different from child)
Telephone: (Home) (Work)
MEDICAL INFORMATION
Allergies
List Allergies?
______
Does your child require any emergency medication? (Ex. Epi Pen):
Name of Medication:
______
Dosage:
______
Other Health Concern _____
EMERGENCY INFORMATION
Father’s Place of
Employment ______
Telephone _____________________________________________
Mother’s Place of
Employment ______
Telephone _____________________________________________
SIGNATURE(S) OF
PERSON(S) TO WHOM CHILD WILL BE RELEASED
Print Name SIGNATURE Telephone
Print Name SIGNATURE Telephone
Print Name SIGNATURE Telephone
Print Name SIGNATURE Telephone