APPLICATION FORM FOR HK CHILD CARE PROGRAM

(SPONSORED BY THE HK RECREATION AUTHORITY)

Child’s

Name__________________________________________________________ Gr.________ Age_______ School_______

Address______________________________________________ Town ________________Zip Code_______

Mother’s

Name________________________________________________ Home Phone (_____)_____________________

Cell Phone (_____)__________________

e-mail ______________________________

Address ______________________________________________ Town _________________Zip Code______

Place of Employment____________________________________ Work Phone (_____)__________________ Address______________________________________________ Town_________________ Zip Code______

Father’s

Name________________________________________________ Home Phone (_____)_____________________

Cell Phone (_____)__________________

e-mail ______________________________

Address ______________________________________________ Town _________________Zip Code______

Place of Employment___________________________________ Work Phone (_____)__________________ Address______________________________________________ Town_________________ Zip Code______

Marital Status: Married_______ Separated________ Divorced________ Widowed_______ Single _______

Child’s Physician & Phone #_________________________________________________________________

If physician cannot be reached, what action should be taken? ________________________________________

__________________________________________________________________________________________

Insurance Carrier ______________________________________ Policy # ____________________________

Child’s Date of Birth: ____________________ (mm/dd/yyyy)

(over)

PERMISSION FOR ANOTHER PERSON TO REMOVE THE CHILD FROM THE PROGRAM

In case of emergency I, ____________________________________________________, give permission to have my child removed from the HK Child Care Program and transported (via ambulance) to the emergency room of Middlesex Memorial Hospital or a medical facility designated by emergency personnel.

In the event that I cannot be reached in an emergency, the HK Child Care Program shall contact one of the following authorized persons who have been notified that they are listed as emergency contacts (at least one person other than parents). Those included are also authorized to pick-up my child.

EMERGENCY NUMBERS

Name & Address Phone (Home & Work) Relationship

1.)_______________________________________________________________________________________

2.)_______________________________________________________________________________________

In addition to the individuals listed above, the following individuals are authorized to pick-up my child at the After School Program.

1.) __________________________________________ 3.)_______________________________________

2.) __________________________________________ 4.) _______________________________________

Persons NOT AUTHORIZED to pick up your child. (If the person is a biological parent, a copy of the court order must be on file with the Director of Child Care) ______________________________________________;

_____________________________________________; ___________________________________________

Allergies and/or Medications __________________________________________________________________

__________________________________________________________________________________________

Physical Limitations/Behavioral Problems _______________________________________________________

__________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

Is there any other significant information which would further contribute to our understanding of your child and his/her needs? _____________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

It is the responsibility of the parents/guardians to update all information.

Parent/Guardian Signature _____________________________________________ Date ________________