(469) 682-7123 or (469) 363-2660

Out of School Time Program/Enrollment Application/Medical Release Please complete the entire form.

Student’s Legal First Name & Middle Initial *

Student’s Legal Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Date of Birth * +

Age *

Grade *

School *

Primary Language *

Enrollment /Start Date * +

Days and Hours child will be in care (place a check next to your selection) *

Monday through Friday Upon school dismissal or 3:00pm to 6:00pm

Other, please specify (days for drop in) Other, please specify (days for drop in)

Does your child have diagnosed food allergies: *

If Yes, List Food Allergies:

Important Health Information: Please list health conditions, allergies (drugs, food, etc.), medications and medical history. (Attach Additional Sheet If needed)

In the event of an emergency your child may be transported to the nearest hospital, Please list your preferred hospital: *

The following Information is required in case of emergency. The Health and Medical Form will be given to medical professionals if an emergency occurs.

Insurance Company *

Phone *

Name of Insured *

Employer of Insured *

Doctor *

Doctor Phone # *

Preferred Clinic/Hospital *

Hospital Phone # *

Parent (Print Name) *

Emergency Contact # *

Relationship to student *

2nd Emergency Contact Person *

Emergency # *

Relationship to Student *

Parent’s Email Address *

Parent’s Signature *

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Date * +