St. Vincent Ferrer School

Registration 2010-2011 School Year

Extended Care Program

PERSONAL /EMERGENCY INFORMATION

Child’s Name__________________________________________Age_______Grade_________

Address______________________________________________________________________

City______________________________________________Zip Code____________________

Mother’s/Guardian Name________________________________________________________

Address_______________________________________________________________________

Home Phone_______________________Work Phohe_________________Cell______________

Father’s/Guardian Name_________________________________________________________

Home Phone_______________________Work Phone____________________Cell___________

Child lives with________Both Parents _________Mother _________Father

Contact Persons in case of emergency (other than parents).

Name_________________________Phone Number__________________Cellular_____________

Name________________________Phone Number____________________Cellular_____________

Allergies_______________________________Physician’s Name____________________________

Name of Preferred Hospital____________________________ or___________________________

Insurance Company_________________________________ Policy #________________________

Special Medical Instructions:_________________________________________________________

My child will be picked up by:

Name____________________________ Telephone #_____________________________

Name_____________________________ Telephone #_____________________________

Do not let my child leave with:

Name____________________________ Name________________________________

Date____________________________Parent/Guardian Signature______________________________