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)                                                     (Cell)                                                    

 

Mother’s Name:                                                   (Maiden Name):                                        ____________

 

Address:                                                                                                                                                          

                                    (if different from child)

 

Telephone: (Home)                                                  (Work)                                                     (Cell)                                                    

 

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)                                                     (Cell)                                                    

 

 

MEDICAL INFORMATION

 

Allergies

List Allergies?

                                                                                                                                                            ______


Does your child require any emergency medication? (Ex. Epi Pen): YES                                  NO                                        

 

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