Forms_afterSchoolCare

SACRED HEART SCHOOL
After School Child Care For Grades K - 5

MOTHER'S NAME:                                                          FATHER'S NAME:

ADDRESS:                                                                       ADDRESS:



EMAIL:                                                                              EMAIL:

HOME PHONE:                                                                 HOME PHONE:

WORK PHONE:                                                                WORK PHONE:

CELL PHONE:                                                                  CELL PHONE:

NAME OF PEOPLE AUTHORIZED TO PICK UP CHILD(REN) {OTHER THAN PARENT(S)}:
1.        2.
3.        4.

EMERGENCY CONTACT {OTHER THAN PARENT(S)}:
NAME / RELATIONSHIP:        PHONE:


NAME OF CHILD(REN):        ALLERGIES / SPECIAL NEEDS:
1.
2.
3.
4.

I (we) agree to make payments as billed by Sacred Heart School in a prompt manner.


PARENT/GUARDIAN SIGNATURE        DATE