SAINT MICHAEL SCHOOL

21 Sixth Street, Lowell, MA 01850

EXTENDED DAY CARE PROGRAM

Registration Form

2008 – 2009

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 Maiden Name: Place of Birth: ____________

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

______

Medications

______

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