AFTER SCHOOL SPORTS ACADEMY CHILD ENROLLMENT FORM

Entrance Date ________________________ Withdrawal Date __________________________

ChildŐs Name _______________________________Sex ___ Age ____ Date of Birth __________

Home Address (Street)  __________________________________________________________

City _____________________________________________State ____________Zip __________

Home Phone Number _________________________________________

FatherŐs Name ___________________________ Home Phone Number ____________________

FatherŐs Home Address (if different from childŐs) Street _________________________________

City _____________________________________________State ____________Zip __________

FatherŐs Place of Employment _______________________________ Work Phone ___________

EmployerŐs Street Address ___________________ City ______________State _____  Zip _____

MotherŐs  Name ___________________________ Home Phone Number __________________

MotherŐs  Home Address (if different from childŐs) Street _______________________________

City _____________________________________________State ____________Zip __________

MotherŐs Place of Employment _____________________________ Work Phone ___________

EmployerŐs Street Address ___________________ City ______________State _____  Zip _____

ChildŐs Living Arrangeme nts:  (check one) (   ) Both Parents  (   )   Mother  (   )  Father   (   )  Other

ChildŐs Legal Guardian(s):  (check one) (   ) Both Parents   (   )   Mother   (   )  Father   (   )  Other

The child may be released to the person(s) signing this agreement or to the following:

*Name ________________________________ Address ________________________________

Telephone Number ______________________________ Relationship to Child ______________

Relationship to Parent(s) or Guardian _______________________________________________

Other identifying information (if any) _______________________________________________

*Name ________________________________ Address ________________________________

Telephone Number ______________________________ Relationship to Child ______________

Relationship to Parent(s) or Guardian _______________________________________________

Other identifying information (if any) _______________________________________________

 


 

Persons to contact in the case of emergency when parent or guardian cannot be reached:

Name ________________________________ Telephone Number_______________________

Name ________________________________ Telephone Number_______________________

Name ________________________________ Telephone Number_______________________

Name of Public or Private School child attends, if any:  ________________________________

 

ChildŐs doctor or clinic name _____________________________________________________

 

Doctor/Clinic phone # __________________________________________________________

 

My child has the following special needs:

 

 

 

The following special accommodation(s) may be required to most effectively meet my childŐs needs while at the center:

 

 

 

 

My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns:

 

 

 

EMERGENCY MEDICAL AUTHORIZATION

 

Should (childŐs name) ______________________________ Date of birth __________________

suffer an injury or illness while in the care of After School SPORTS Academy and  the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary.  I (We) shall assume responsibility for payment for services .

 

Parent/Guardian:  ______________________________________________________________

                                                                                                            Signature

Date:  _________________________

 

Facility Administrator/Person-In-Charge:  ___________________________________________

                                                                                                            Signature

Date:  _________________________

Parental Agreements with Child Care Facility

The After School SPORTS Academy agrees to provide child care for

NAME OF CHILD

Mon

Tue

Wed

Thu

Fri

From

a.m.

Until

p.m.

 

 

 

 

 

 

 

 

 

 

                                                                                          (Circle Days of week)                        (write in start time to end time)

My child will participate in the following meal plan (circle applicable meals and snacks):

 

 

Breakfast

 

Morning Snack

 

Lunch

 

Afternoon Snack

 

Evening Snack

 

Dinner

 

Bedtime Snack

 

 

 

Before any medication is dispensed to my child, I will provide a written authorization, which includes:  date; name of child; name of medication; prescription number; if any; dosages; date and time of day medication is to be given.  Medicine will be in the original container with the childŐs name marked on it.

 

My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person authorized by the parent(s), or facility personnel.

 

I acknowledge it is my responsibility to keep my childŐs records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, childŐs physician, childŐs health status, nutritional needs, and immunization records, etc.

 

The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.

 

The After School SPORTS Academy agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than (2) feet deep.

 

I authorize the After School SPORTS Academy to obtain emergency medical care for my child when I am not available.

 

I have received a copy and agree to abide by the policies and procedures for After School SPORTS Academy.

 

I understand that the facility will advise me of my childŐs progress and issues rationing to my childŐs care  as well as any individual practices concerning my childŐs special needs.  I also understand that my participation is encouraged in facility activities.

 

Signed:  _______________________________________________ Date:  ___________________

                  (Parent/Guardian)

Signed:  _______________________________________________ Date:  ___________________

                  (Facility Administrator/Person-In-Charge)