Tiger Care Cathedral-Carmel School 2014-2015 Registration Form Child’s name:________________________________________________________________________ Mailing address:______________________________________________________________________ City:____________________________________ State:________ Zip Code:_____________________ Birth date:______________________________ Grade:__________ Gender:____________________ Applying for-circle one: Full-time Part time (2 days/week) (3 days/week) Drop-in Mother’s name:________________________________________ Home phone:________________ Cell phone:____________________________________________ Work phone:_________________ Employed by:________________________________________________________________________ Father’s name:____________________________________ Home phone:_____________________ Cell phone:________________________________________ Work phone:_____________________ Employed by:________________________________________________________________________ Parent’s Marital Status: Married Single Divorced Separated Custody arrangements:_______________________________________________________________ _____________________________________________________________________________________ Physician’s name:____________________________________________________________________ Address:____________________________________________ Phone:__________________________ Hospital of choice:____________________________________________________________________ Does your child have any allergies, medical conditions, or special needs that require medications or accommodations in order to participate in this program. If so, please explain.______________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Emergency Contact/Other than parent or doctor: (This person will be allowed to pick up your child.) Name:______________________________________________ Relationship:____________________ Address:____________________________________________ Phone number:_________________ My child can be released only to the person signing this application, the emergency contact, or to the following person(s): _______________________ _______________________ ______________________ _______________________ _______________________ ______________________ I hereby grant permission for: ____ my child to use all of the playground equipment and participate in all the activities of the school. ____ any employee of Tiger Care to take whatever steps may be necessary to obtain emergency medical care if warranted. ____my child to watch PG movies which will be shown at the teacher’s discretion. ____ the administering of topical cream. ____ special circumstances_____________________________________________ Parent Signature________________________________________________ Date:_______________ This form cannot be processed until it is signed by a legal guardian and the $25.00 registration fee has been paid. Please return this form with the $25.00 /family non-refundable Registration Fee. PLEASE MAKE CHECK PAYABLE TO: CCS Tiger Care 848 St. John Street Lafayette, LA 70501 If you have any questions, please contact: Angela Cox, Tiger Care Manager Phone (337) 501-0909 or 235-5577 Fax 337-261-9493