Before & After School Registration Form

Please complete this form if you are registering your child for the Before & After School Program.

Name of Child * First Last
Date of Birth * / MM / DD YYYY
Grade Entering
Parent #1 Name * First Last
Parent #1 Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Parent #1 Home Phone * - (###) - ### ####
Parent #1 Cell - (###) - ### ####
Parent #1 Work Phone - (###) - ### ####
Parent #1 Email
Parent #2 Name First Last
Parent #2 Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Parent #2 Home Phone - (###) - ### ####
Parent #2 Cell - (###) - ### ####
Parent #2 Work Phone - (###) - ### ####
Parent #2 Email
Emergency Contact Information

Please input the Emergency Contact Information for your child below.
Emergency Contact Name * First Last
Relation to Child *
Emergency Contact Home Phone * - (###) - ### ####
Emergency Contact Cell Phone - (###) - ### ####
Permissions to Pick up Child

Please input the name(s) of at least one person who has permission to pick up your child from the Before & After School Program
Permission to pick up child * First Last
Permission to pick up child First Last
Permission to pick up child First Last
Permission to pick up child First Last
Permission to pick up child First Last
Medical Information
Is your child's Tetanus shot current for September 2010 through September 2011? * Yes No
Child's Physician First Last
Physician Phone - (###) - ### ####
Physician Phone - (###) - ### ####
Is your child covered by an insurance plan? * Yes No
Name of Insurance Company
Please list all allergies your child has (if none, please type "none known" in the box below). *
Please list all medications your child is on (if none, please type "none" in the box below). *
Has your child had an IEP behavioral modification plan? * Yes No
Please list any health conditions your child currently has
I give Hermon Recreation permission to use my child's captured media images for advertising and special announcements * Yes No
By typing your name in this field, you hereby attest that the information provided in this form is truthful and accurate and that you have reviewed the release information (please see below)
Release Signature * First Last
Date * / MM / DD YYYY
Release Information: I hereby authorize my child to participate in Hermon Recreation Department programming. I agree to hold harmless the Hermon Recreation Department, the Town of Hermon and the Hermon School Department for any injuries that could arise during participation. I authorize the Hermon Recreation Department and its employees to act in my place in all respects and with all immunities should the need arise to administer emergency medical care.

Before & After School Registration Form

Before & After School Registration Form

Emergency Contact Information

Permissions to Pick up Child

Medical Information

By typing your name in this field, you hereby attest that the information provided in this form is truthful and accurate and that you have reviewed the release information (please see below)