Tiger Care - Cathedral

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