Downtown - Enrollment Form - First Presbyterian Day School printable pdf download

First Presbyterian Day School Downtown

Extended Day Program

682 Mulberry Street

Macon, Georgia 31201

(478) 254-2906

Enrollment Application

CHILD’S NAME_________________________ Sex_____ Age_____ Date of Birth ________Grade_________

Address_______________________________________________ Home Phone ______________________

FATHER’S NAME___________________________ Work Phone ______________ Hours_________________

Home Address_________________________________________________ Cell Phone___________________

Employer _________________________________ Employer Address_________________________________

MOTHER’S NAME___________________________ Work Phone _____________ Hours _________________

Employer_________________________________ Employer Address _________________________________

Home Address____________________________________________________ Cell Phone _______________

Child’s Living Arrangements ( ) Both Parents ( ) Mother ( ) Father ( ) Other___________________________

Child’s Legal Guardian(s) ( ) Both Parents ( ) Mother ( ) Father ( ) Other______________________________

EMERGENCY CONTACTS and AUTHORIZED RELEASE (when Parents cannot be reached)

*** Please fill out completely ***

Name __________________________________________ Relationship to Child ________________________

Address _____________________________________________ Phone Number________________________

Name __________________________________________ Relationship to Child ________________________

Address ______________________________________________ Phone Number________________________

Name__________________________________________ Relationship to Child _________________________

Address ______________________________________________ Phone Number________________________

Emergency Medical Authorization

Should your child suffer an injury or illness while in the care of First Presbyterian Day School Downtown Extended

Day Program and the facility is unable to contact you (the parent[s]) immediately, it shall be authorized to secure

such medical attention and care for your child as may be necessary. The parent shall assume responsibility for

payment for services.

Physician /Clinic Name _____________________________________Phone Number______________________

Known medical conditions/allergies/daily medication/ health concerns: __________________________________

__________________________________________________________________________________________

My child has the following special need(s) and/or accommodation(s):___________________________________

__________________________________________________________________________________________

Parent/Guardian Signature: _________________________________________ Date ______________________

Downtown - Enrollment Form - First Presbyterian Day School