Application
for Enrollment
2008 After-School
Program / Summer Program
Check One: ▢ After School Program ▢ Summer Program
Childs Name
_______________________________ Date of Birth ___________
School _____________________________________
Grade ________________
Parents/Guardians Name
___________________________________________
Home Address
_____________________________________________________
Home Phone Number
_____________________Email _____________________
Parents/Guardians Work (Name
& Address) __________________________
__________________________________________________________________
Work Phone Number
______________________ / _______________________
Cell / Pager Number
______________________ / ________________________
Please list two emergency
contacts if the parent(s) or guardian(s) cannot be located promptly:
Primary Emergency Contact:
Name______________________________
Relationship ___________________
Phone Number _____________________
Cell Phone # ____________________
Address
__________________________________________________________
Secondary Emergency Contact:
Name______________________________
Relationship ___________________
Phone Number
_____________________ Cell Phone # ____________________
Address
__________________________________________________________
The following people will be
allowed to pick up and drop off my child. Please inform them that a picture ID
will be requested.
1. Name
____________________________________________
2. Name
____________________________________________
3. Name
____________________________________________
Please list any special
information concerning the child’s growth and development, any special needs,
and/or allergies:
Please list those persons
who are allowed to pick up and drop off my child:
2008 PHOTOGRAPHY RELEASE
My child may be
photographed/videotaped at the facility ▢yes ▢no; by the media ▢ yes ▢ no.
MY CHILD
HAS MY PERMISSION TO GO AND PARTICIPATE
IN ALL FIELD TRIPS WITH ATA Black Belt Academy, after school and Summer Camp in
approved vehicles with authorized staff and volunteers. All trips will be
announced prior to each excursion and an individual permission slip must be
signed and returned to the center in order for your child to attend the field
trip
▢ yes ▢ no. I understand a separate
permission slip must be signed for each field trip.
The facility has my
permission to obtain emergency medical treatment for my child ▢ yes ▢ no. If no, list instructions _______________________________
__________________________________________________________________
INSURANCE STATEMENT
I am aware the
▢ A record of immunizations according to the schedules and forms
prescribed by the Mississippi State Department of Health (MSDH Form 121) has
been turned in.
AGREMENT
TO TERMS
We require a two week notice
prior to withdrawal from out program.
I have received information
concerning the facilities policies and procedures and a copy of the Child Care
Regulations Summary for Parents.
I have read and understand and
agree to all the above policies and terms.
______________________________________
_____________________
Parent/Guardian Signature Date
Date of enrollment:
_____________________________________
Date of Withdrawal:
_____________________________________
Reason for Withdrawal:
_______________________________________________________________
______________________________________ _______________________
Program Owner Date