Student Enrollment Information Form (Page 2 of 2) in pdf

Student Name: ____________________________________________________ Grade_______________

Last, First and Middle

EMERGENCY INFORMATION AND CONTACTS

In case of accident or serious illness, the school will contact a parent. If the school is unable to reach a parent,

I/We hereby authorize the school to call the physician indicated below and to follow their instructions. If it is

impossible to contact this physician, we hereby authorize any licensed physician to render necessary treatment.

Parent(s) will assume all financial responsibility for injuries or illness sustained by our child. In case of an

emergency, if a parent cannot be located, I/we authorize school authorities to arrange for ambulance services.

Your Hospital-Medical Insurance Company__________________________________________________

Does Student have any allergy/health/behavioral conditions?

Yes _____

No_____

Allergy ___________If yes, briefly describe: _____________________________________________

Medication student takes: _________________________________________________________________

Wears: Glasses_______

Contacts_______

Hearing Aid________

None_______

Doctor’s Name: _________________________________________Phone Number: ________________

Dentist’s Name: _________________________________________Phone Number: ________________

Does this student have any special educational needs? ____No

___Yes If yes, please explain______

__________________________________________________________________________________________

__________________________________________________________________________________

Emergency contacts if parents cannot be reached:

1. Name _____________________________________________

Address____________________________________________

Telephone numbers _______________________ (home) __________________________ (cell)

2. Name _____________________________________________

Address____________________________________________

Telephone numbers _______________________ (home) __________________________ (cell)

REGISTRATION FOR OTHER CACS SERVICES

Before Care

______Daily

______Occasionally

After Care

______Daily

______Occasionally

Extended Care (3K/4K Students) ______Daily

______Occasionally

_____________________________

___________________________

Father Signature/Date

Mother Signature/Date

Student Enrollment Information Form Page 2