*Your Email

    * Childs Name

    * Childs Birthdate

    * ChildsAddress

    * Mothers Name/Legal Guardian

    * Mother/Guardian's Number

    * Mothers/Guardians Address

    * Mother's Business Name

    * Mother's Business Number

    * Mother's Business Address

    * Father's Name/Legal Guardian

    * Father/Guardian's Number

    * Father/Guardians Address

    * Father Business Name

    * Father Business Number

    * Father Business Address

    * Emergency Contact Person 1

    Emergency Contact Person 2

    Emergency Contact Person 3

    * Emerg Contact 1 # while child is in care

    Emerg Contact 2 # while child is in care

    Emerg Contact 3 # while child is in care

    * Person 1 to whom child may be released

    Person 2 to whom child may be released

    Person 3 to whom child may be released

    * Person 1 address

    Person 2 address

    Person 3 address

    * Person 1 Number while child is in care

    Person 2 Number while child is in care

    Person 3 Number while child is in care

    * Name of child's Physician/Medical Care Provider

    * Medical Care Provider's Number

    * Medical Care Provider's Address

    Special Disabilities (If any)

    Medical or Dietary Information necessary in an emergency situation

    Allergies (Including Medication Reaction)

    Medication, Special Conditions

    * Additional information on special needs of child

    * Health Insurance Coverage for child or Medical Assistance benefits

    * Policy Number

    [heading "Parent Signature is required for each item below to indicate parental consent, if not use N/A for decline"]

    * Obtaining Emergency Medical Care (DO NOT USE TOUCHSCREEN)

    * Walks and Trips (DO NOT USE TOUCHSCREEN)

    * Transportation by the Facility (DO NOT USE TOUCHSCREEN)

    * Admin. of minor first-aid procedures (DO NOT USE TOUCHSCREEN)

    * Swimming (DO NOT USE TOUCHSCREEN)

    * Wading (DO NOT USE TOUCHSCREEN)

    * Signature of Parent or Guardian (DO NOT USE TOUCHSCREEN)

    * Date

    * Signature of Parent or Guardian (DO NOT USE TOUCHSCREEN)

    * Date