Registration Form

2007-2008

St. Augustine Cathedral School After-School

Child’s name

 

____________________              _____                              ______________________

Grade                                                              Age                                   Birth Date

 

_________________________________                    _____________________________

Mother’s Name                                                                                         Father’s Name

 

Address:___________________________________________________

 

         _______________________________________________________

              City                                                             State                                          Zip

 

Phones:   (home)_____________________________

 

______________________________                    ________________________

Mom work                                                                                                 Dad work

 

______________________________                     ________________________

Mom cell                                                                                                     Dad cell

 

______________________________                     ________________________

Mom pager                                                                                                Dad pager

 

Emergency Contacts:

 

_______________________________               _______________________________

name                                   relationship                          phone number/s

 

_______________________________               _______________________________

name                                   relationship                          phone number/s

 

_______________________________               _______________________________

name                                   relationship                          phone number/s

 

 

My child will attend the St. Augustine Cathedral School After School Care program

 

Occasionally   _________                    Regularly_________  (check one)

 

I plan on my child attending the After School Care Program

 

MONDAY

_______________________________________________________________________

TUESDAY

_______________________________________________________________________

WEDNESDAY

_______________________________________________________________________

THURSDAY

_______________________________________________________________________

FRIDAY

_______________________________________________________________________

 

 

I, __________________________________, certify that my child is in good health and

    Parent name

is free from any and all communicable disease or illness.  I further certify that all of my child’s immunizations are up to date.

 

Parent Signature_________________________________________

 

Date:__________________________

 

I hereby agree to follow all rules as listed in the handbook for this program and as set by the Director of the program.  I understand that this program will be operated in a similar manner to the rules and expectations of the school, in areas of language, behavior, and acceptable activities.  I further understand my obligations regarding payment and timely pick-up of my child/children.

 

 

Parent Signature/date