HARWICH COMMUNITY LEARNING
CENTER
AFTER SCHOOL PROGRAM
It is necessary to send a NOTE
to your child's teacher informing him/her that your child
will be attending the program.
Click
Here for Printable Registration Form |
| CHILD INFORMATION: |
| Name: |
| Grade |
Teacher |
Date of Birth |
| PARENT/GUARDIAN INFORMATION: |
| Name: |
| Address: |
| Mailing Address |
| Home Phone |
Work Phone |
| E-Mail: |
Cell Phone: |
| 2nd PARENT/GUARDIAN INFORMATION: |
| Name: |
| Address: |
| Mailing Address: |
| Home Phone: |
Work Phone |
| E-Mail: |
Cell Phone: |
| EMERGENCY CONTACT (OTHER THAN ABOVE - MUST BE
LOCAL) |
| Type: (i.e. Uncle, Aunt, etc.) |
Name |
| Phone |
| Type: (i.e. Uncle, Aunt, etc.) |
Name |
| Phone: |
| Type: (i.e. Uncle, Aunt, etc.) |
Name |
| Phone |
| MAY PICK UP MY CHILD |
| Person's Name |
| Person's Name |
| MAY NOT PICK
UP MY CHILD |
| Person's Name |
| Person's Name |
FOOD ALLERGIES: |
| MEDICAL/BEHAVIORIAL CONCERNS: |
| |
Pictures can/cannot (circle one) be taken of
my child by the local media.
Pictures can/cannot (circle one) be put on the HCLCP website.
I authorize/do not authorize (circle one) the program to
administer first aid treatment and, if necessary, to take
my child to ____________________ Center/Hospital and authorize
treatment by the doctor on call if own physician cannot be
reached. |
| Physician's Name: |
Phone: |
| My Student has permission to travel by bus to
attend the filed trips during the after school program with
the Harwich Community Learning Center Programs. |
| Parient/Gardian's Signature |
Date: |
