Registration and Insurance Waver

2009-2010 After School Program Registration Form

Childs Name: _______________________________________________________

Parents/Guardians Names: ____________________________________________

Childs Birthday: _________________= _______ Age: _________ Grade: _________

Child’s School: ________________________________

Address: ___________________________________________

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        =       ___________________________________________

Home Phone Number: ______________________________

Work Number: ___________________________

Cell Phone Number: _______________________

Emergency Contact Information:

Name: _________________________________        =             &nb= sp;            =                 =             &nb= sp;Relationship to child: _______________________

Phone Number: ____________________= __ Cell Phone Number: ________________

Address: __________________________________

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I, ________________, give permissi= on for my son/daughter to attend the Linnville Lighthouse = After School Program. I will not hold St. John’s Lutheran Church or the After School Program responsible for any accidents that occur while my child is in attendance.

Parent Signature: ________________= _____________________ Date: _____________

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I give permission for proper emerg= ency medical treatment to be given to my child in the event of an emergency.

Parent Signature: ________________= ______________________ Date: ____________

I do not give permission for emerg= ency medical treatment to be given to my child in the event of an emergency.

Parent Signature: _______________________________________ Date: ___________=

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