Beyond The Bell Registration Form - Village Of Lake In The Hills Parks & Recreation Department Page 2
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1
2Registration Form
*
*
Child’s Name
M
F
Birthdate
Grade Level
Days Attending
M
T
W
Th
Fr
(2015/2016)
*
*
*
*
Child Lives With
Mom
Dad
Both
Other
,
Child
s Home Address
Home Phone
Alternate Phone
Mother’s Name
Father’s Name
Work Phone
Work Phone
Cell Phone
Cell Phone
EMERGENCY CONTACT/PERSON(S) WITH PERMISSION
Name
Relation
Home Phone
Cell Phone
Name
Phone #
Relation
Name
Phone #
Relation
ANYONE NOT AUTHORIZED TO PICK UP?
*
*
Does your child require any medications during ETC hours?
Yes
No
(If YES, an authorization form must be filled out and kept on file)
*
*
Does your child have any allergies? (animals, food, medications, plants)
Yes
No
Please explain
*
*
Does your child have any health problems that would limit participation?
Yes
No
(If YES, an authorization form must be filled out and kept on file)
Please explain
Name of Physician
*
*
Does your child have any special needs that require accommodations or special assistance?
Yes*
No
(*If YES, depending on the assistance required, participation may be delayed up to 4 weeks to provide any necessary accomodations.)
Please explain
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