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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 ParentSignature:________________________________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 anNote: We will not release you; child to persons not listed above unless
you call and provide the security code.
Security Code:_________________________