CHRIST THE KING AFTER SCHOOL PROGRAM
CHILD’S NAME______________________ GRADE (2005-2006)_______
ADDRESS___________________________________________________
PHONE #'s HOME_______________ WORK (M)____________(F)___________
Cell Phone #s (M)______________ (F)________________
EMERGENCY CONTACT:
I will be using the Program:
Weekly for: 1 hour___ 2 hours___ 3 hours___
Now & Then___ Which days? (if known)________________
List those who are authorized to pick up your child.
(We will not release your child to anyone whose name does not appear on this list.)________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Please list any Allergies or other conditions you feel we should be aware of.
____________________________________________________________
____________________________________________________________
Will you be using our program for your Emergency Dismissal Plan?
YES_______NO_______
****** Once school opens for the day, we are here until 6 PM. ******