Extended Day Registration Form printable pdf download

Office Use:

BLESSED SACRAMENT SCHOOL EXTENDED DAY PROGRAM

Reg. paid

STUDENT REGISTRATION (rev. 6/16)

Reg. date

CHILD'S NAME ___________________________________________________ CHILD'S SEX _________ GRADE __________________

CHILD'S NICKNAME _________________ CHILD'S ADDRESS __________________________________ BIRTH DATE ____________

MARITAL STATUS OF PARENTS ____________________________

LEGAL CUSTODY OF CHILD _________________________________________________

FATHER'S/GUARDIAN’S NAME ___________________________________________________________________________________

ADDRESS_______________________________________________________ CITY ___________________________________

STATE_____________________ ZIP _________________EMAIL__________________________________________________

PLACE EMPLOYED____________________________________________WORK HRS.__________CITY _________________

HOME # __________________________ WORK # __________________________ CELL # _____________________________

MOTHER'S/GUARDIAN’S NAME___________________________________________________________________________________

ADDRESS_______________________________________________________ CITY ___________________________________

STATE_____________________ ZIP _________________EMAIL__________________________________________________

PLACE EMPLOYED_____________________________________________WORK HRS._________CITY__________________

HOME # ___________________________ WORK # ___________________________ CELL # ___________________________

EMERGENCY CONTACTS (other than Parents)

1. NAME _________________________________ ADDRESS

ZIP

RELATIONSHIP_____________DAY # ___________________EVE. # ____________________ CELL # ___________________

2. NAME _________________________________ ADDRESS

ZIP

RELATIONSHIP_____________DAY # ___________________EVE. # ____________________ CELL # ___________________

AUTHORIZED TO PICK UP:

NAME:_______________________________ NAME: ________________________________ NAME: _____________________________

PERSON(S) NOT AUTHORIZED TO PICK UP:

NAME: ______________________________ NAME: ________________________________ NAME: _____________________________

Chronic Physical Problems, Allergies/Pertinent Developmental Information/Special Accommodations Needed (note N/A if none apply)

__________________________________________________________________________________________________________________

Name and phone number of child’s physician ___________________________________________________________________________

OTHER SCHOOL/PROGRAM PRESENTLY ATTENDING: ______________________________________________________________

PHONE______________________ GRADE/CLASS ______________________________________________________________________

PREVIOUS SCHOOLS/PROGRAMS ATTENDED: ______________________________________________________________________

__________________________________________________________________________________________________________________

DATE & PHONE ___________________________________________________________________________________________________

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Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.

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NOTE: Sections 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial

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Extended Day Registration Form