• Sutton B&ASC/Summer Care Program Registration Form

    Name of Child:__________________________________Grade in Sept._______

    Please Check all that apply:

    _______Summer Care

    Days of enrollment: _____ M _____Tu _____W _____Th _____F

    _______Full Day Program _____ Half Day Program

    _____ 7:00 AM-1:00 PM

    _____ 12:00 PM-6:00 PM

    $15.00 Registration Fee (non refundable) : _____ Paid _____ Not Paid

    _______After School Care

    Days of enrollment: _____ M _____Tu _____W _____Th _____F

    $15.00 Registration Fee (non refundable) : _____ Paid _____ Not Paid

    _______Before School Care

    Days of enrollment: _____ M _____Tu _____W _____Th _____F

    $5.00 Registration Fee (non refundable) : _____ Paid _____ Not Paid

    Name of Parent:___________________________Phone #:_____________

    Phone #:_____________

    Name of Parent:___________________________Phone #:____________

    Phone #:____________

    *

    Handbook that was issued.

    I have read, understand and will adhere to the policies stated in the Parent

    Signature:________________________________Date:___________

    Child’s Information Form

    Child’s Name:________________________ Date of Birth______________

    Address:______________________________________________________

    Telephone:__________________

    Is there documentation for a physical exam and immunization record at your

    child’s school? Yes_______ No_______

    List any special limitation or concerns your child may have:

    List any special interests your child may have:

    Identifying information:

    eye color:___________ height:______________ sex:_______________

    hair color:____________ weight:_____________ race:_______________

    other:_____________

    Signature:___________________________________ Date:_____________

    First Aid and Emergency Care

    Child’s Name:____________________________ Date of Birth:________

    I understand that the Sutton B&ASC/Summer Care Program has a nurse on

    site and the staff are trained in First Aid and CPR. I give them my

    permission to treat my child if needed.

    I understand I will be contacted immediately in the event of an emergency,

    however, if I am unable to be reached, I give permission for the Sutton

    B&ASC/Summer Care Program to contact the following persons:

    Name:_________________________________ Phone (h)____________

    Relationship to the child:____________________ Phone (w)__________

    Name:_________________________________ Phone (h)____________

    Relationship to the child:____________________ Phone (w)__________

    I herby authorize the program to transport via Ambulance to

    ____________________________________ and/or the nearest hospital.

    Child’s Allergies:____________________________________________

    Child’s Health Conditions:_____________________________________

    Signature:_____________________________________ Date:__________

    Authorized Pick Up

    I give permission for the following adults to pick up my child from the

    Sutton B&ASC/Summer Care Program.

    Name:__________________________________Phone (h):__________

    Relationship to child________________________Phone (w):_________

    Name:__________________________________Phone (h):__________

    Relationship to child________________________Phone (w):_________

    Name:__________________________________Phone (h):__________

    Relationship to child________________________Phone (w):_________

    Please note

    authorized pick-up will be asked to produce a photo ID before we can

    release your child to them.

    Security Code

    The security code is to ensure the safety of your child. If a situation occurs

    when you are unable to pick your child from the program and you need

    someone that is not on the Authorized Pick Up list, please follow the

    following procedure:

    1) Call the site your child is enrolled

    2) Be certain to speak with’ the Site Supervisor

    3) Inform the Site Supervisor of the person you authorize to pick up your

    child on that given day.

    4) The Site Supervisor will ask you for your security code (listed below) for

    identification purpose.

    : to ensure the safety of your child the adults you list as an

    Note: We will not release you; child to persons not listed above unless

    you call and provide the security code.

    Security Code:_________________________