Our Lady of the
Angels School |
Before/ After
School Registration |
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| Student Information |
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| STUDENT NAME (last/first) _____________________________________Grade
______ Allergies_________________________ |
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| STUDENT NAME (last/first) _____________________________________Grade
______ Allergies ________________________ |
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| STUDENT NAME (last/first) _____________________________________Grade
______ Allergies ________________________ |
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| Parent Information |
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| Mother/Guardian _____________________________________________________________________________ |
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| Place of Employment _________________________________________
Phone _________________________ |
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| Cell/Car Phone _______________________________________________________________________________ |
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| Father/Guardian ______________________________________________________________________________ |
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| Place of Employment _________________________________________
Phone _________________________ |
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| Cell/Car Phone _______________________________________________________________________________ |
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Emergency Physician _________________________________________Phone____________________________ |
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| Child's Physician _____________________________________________Phone
____________________________ |
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| Emergency Release |
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| In the event of an accident or serious injury and I cannot
be reached at the numbers above, I hereby authorize the school
to arrange emergency transportation to the nearest hospital
emergency room for treatment. |
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| __________________________________________________________________________________________________________________ |
| Signature of Parent/Guardian Date |
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| Billing Information |
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| Bill to Name ____________________________________________________________________________________ |
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| Address ________________________________________________________________________________________ |
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| Registration |
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| After School Please indicate pick up time. Latest possible
pickup is at 5:30. |
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| Monday ________Tuesday _________Wednesday _________Thursday
________ Friday_____________ |
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| Before School Please indicate drop off time. |
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| Monday ________Tuesday _________Wednesday _________Thursday
________ Friday_____________ |
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| Handbook. I agree to the stated Policies and Procedures of
the Before and After School Handbook, and give my child permission
to participate fully in this program. I understand that my child
may be suspended from the program for faililng to adhere to
stated policies. |
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| Please list on the back of this form any person(s) you would
allow to pick up your child should you be unavailable. |
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| __________________________________________________________________________________________________________________ |
| Parent/Guardian Signature Date |