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St. Ambrose Extended Day Registration 2022-2023
Child First Name:
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Child Last Name:
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Nickname:
Child's Birthdate:
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Sex:
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Male
Female
Grade:
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Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
Child's Street Address:
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City:
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State:
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Zip Code:
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Please list any chronic physical problems or special accommodations needed. If this does not apply, please write N/A.
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Please list any previous child day care programs attended. If this does not apply, please write N/A.
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Parent #1 First & Last Name:
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Parent #1 Street Address:
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City:
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State:
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Zip Code:
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Parent #1 Phone Number(s):
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Parent #1 Email Address:
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Parent #2 First & Last Name:
Parent #2 Street Address:
City:
State:
Zip Code:
Parent #2 Phone Number(s):
Parent #2 Email Address:
If another person or agency has legal custody of the child, please write the name, address and phone numbers for that person or agency below. If this does not apply, please write N/A.
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Emergency Contact #1 First & Last Name:
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Emergency Contact #1 Street Address:
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City:
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State:
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Zip Code:
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Emergency Contact #1 Phone Number(s):
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Emergency Contact #2 First & Last Name:
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Emergency Contact #2 Street Address:
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City:
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State:
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Zip Code:
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Emergency Contact #2 Phone Number(s):
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Please list any additional people who ARE authorized to pick up your child that are not already listed on this form. If this does not apply, please write N/A.
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Please list any person(s) NOT authorized to pick up your child. If this does not apply, please write N/A.
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Please list all known allergies/intolerances and action to be taken in an emergency. If this does not apply, please write N/A.
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Child's Physician:
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Physician's Phone Number:
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The child day center agrees to notify the parents/guardians whenever the child becomes ill and the parents/guardians will arrange to have the child picked up as soon as possible if so requested by the center. The parents/guardians agree to inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.
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Agree
The parents/guardians authorize the child day center to obtain immediate medical care if any emergency occurs when the parents/guardians cannot be located immediately.
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Agree
Date:
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Electronic Signature
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