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After School Program for Kindergarteners
2015/16 School Year
Contact & Health Form
Child’s name:
Date of Birth:
Age:
Child’s Primary Address: (Street, Apt. # and/or PO Box, City, State, Zip)
Parent/Guardian 1 Name:
Parent/Guardian 2 Name:
Parent/Guardian 1 Home Address (if different):
Parent/Guardian 2 Home Address (if different):
Parent/Guardian 1 Business Phone:
Parent/Guardian 2 Business Phone:
Parent/Guardian 1 Home Phone:
Parent/Guardian 2 Home Phone:
Parent/Guardian 1 Cell Phone:
Parent/Guardian 2 Cell Phone:
Parent/Guardian 1 Email:
Parent/Guardian 2 Email:
Emergency Contacts (other than Parent/Guardian):
You must list at least one emergency contact. Please include phone numbers.
1. Name:
Relationship to Child:
Phone Numbers:
2. Name:
Relationship to Child:
Phone Numbers:
3. Name:
Relationship to Child:
Phone Numbers:
Are there any cognitive, physical, or emotional needs that your child may have at this time?
Please identify:
And if so, are there any techniques you know of that will aid us in supporting your child’s progress?
Does your child have any allergies to the outdoors, medicines, food, clothing, animals, etc.?
Please list:
Is your child currently taking any medications that we should know about?
Please list:
Medical Information
Is your child covered under your families insurance? Yes _____
No______
Doctors Name:
Phone:
Insurance Co.:
Policy #:
Parental Permission
Island Kids, Inc, has permission for my child to participate in programs that are planned and
supervised by Island Kids. Island Kids, Inc. has permission to treat my child for routine, minor
injuries such as scrapes and bruises. In the event that my family physician cannot be contacted in
an emergency, I hereby grant Island Kids, Inc. Staff permission to bring my child to be treated at a
hospital emergency room.
Signature:
Print Name:
Date:
Relationship to Child: