C.A.R.E.S. Registration

Child’s Last Name ______________________ First _________________________

Home Address __________________________________ Phone # ________________

Date of Birth ___________________ Grade (August 2010) _________________

Parent Information

Mother’s Last Name _____________________ First _________________________

Home Phone # __________________ Cell Phone #/Beeper __________________

Work Place _____________________ Work Phone #/Extension _______________

Father’s Last Name _____________________ First _________________________

Home Phone # __________________ Cell Phone #/Beeper __________________

Work Place _____________________ Work Phone #/Extension _______________

Email (Please Print)________________________________________________________

The following persons, other than parents, HAVE BEEN AUTHORIZED to pick up my child from C.A.R.E.S. in the event of an emergency.

Name/Relation __________________________ Phone # ______________________

Name/Relation __________________________ Phone # ______________________

SPECIAL INSTRUCTIONS

Doctor ______________________________ Phone # ______________________

Allergies ____________________________ Chronic Illness _________________

I give permission to the C.A.R.E.S. staff to act in the event of an emergency when a parent cannot be reached (please sign) _____________________________

The following person(s) MAY NOT pick up my child.

________________________________________________________________________

________________________________________________________________________

Please check all times that your child (children) will be attending C.A.R.E.S.

AM Program 7:00 AM – 8:45 AM ______________

PM Program 3:15 PM – 4:30 PM ______________

3:15 PM – 5:30 PM ______________

Half Day/Full Day Program ______________

My child (children) will attend

5 days per week ______________

Part-time (Please list days) ______________

***** $50 Registration Fee per family ***** Check # ___________

Date Rec’d ________