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Goodpasture Christian School
2015/2016 Extended Care
REGISTRATION FORM
Name:
Grade Entering in the fall of 2015
Birth Date:
Home Address:
Home Phone:
Home Email:
Father's Name:
Employer:
Work Phone:
Cell Phone:
Work Email:
Mother's Name:
Employer:
Work Phone:
Cell Phone:
Work Email:
Do parents live together?
Yes ___
No ___
If NO, who has legal custody?
To whom may the child be released? (Identification WILL be required at time of release)
Name: _________________________________________
Relationship:
Name: _________________________________________
Relationship:
Name: _________________________________________
Relationship:
Please note any alergies or physical, emotional or learning problems the GCS Extended Care Staff should be aware of:
EMERGENCY CONTACT
Name: __________________________________________
Relationship:
Phone: __________________________________________
Name of child's physician:
Phone:
Preferred hospital: _______________________________________________
SIGNATURE(S) OF PARENT OR LEGAL GUARDIAN
Date