Summer Registration - Our Lady of the Holy Souls School

Child's Name *

Date of Birth *

Current Grade *

Child's Current School *

Second Child's Name (Type N/A if this does not apply)

Date of Birth (Type N/A if this does not apply)

Grade (Type N/A if this does not apply)

Second Child's Current School (type N/A if this does not apply)

Third Child's Name (Type N/A if this does not apply)

Date of Birth (Type N/A if this does not apply)

Grade (Type N/A if this does not apply)

Current School (type N/A if this does not apply)

Parent/Responsible Party's Contact Information

Parent/Responsible Party 1 - Last/First Name *

Parent/Responsible Part 2 - Last/First Name (Type N/A if this does not apply) *

Street, City, State, Zip *

Home, Work & Cell Numbers *

Email Address(s) *

Place(s) of Employment *

Enrollment Information

Enrollment Status: * (1 required)

Weekly Daily (Check Days Below) Drop-In

Days Attending for Children Attending Daily

Monday Tuesday Wednesday Thursday Friday

EMERGENCY CONTACT (if parents can not be reached)

Name *

Relation to Child *

Home, Work and Cell # *

Medical Information

Health Insurance Provider *

Doctor with Phone Number *

Dentist with Phone Number (Type N/A if this does not apply) *

In case of EMERGENCY, if the undersigned parent(s) or responsible party cannot be reached by phone, consent is given to take my child/children to:

Hospital Name *

The aforementioned doctor, or in the event of his unavailabliity, any doctor on staff of said hospital, is authorized to utilize whatever medical techniques are deemed necessary including surgery. The undersigned acknowledge their responsibility for all reasonable medical expenses so incurred.

Allergy or Medical Condition

Does your child have an allergy or medical condition? * (1 required)

Yes No

Describe the Allergy or Medical Condition (Type N/A if this does not apply) *

Child/Children's Names Affected (Type N/A if this does not apply) *

An employee of Extended Care has my permission to apply sunscreen when necessary. * (1 required)

Yes No

Approved Pick-Up List

The following individuals have permission to pick up my child from Holy Souls Extended Care. (Type N/A if this does not apply)

Anyone not listed must have written permission from a parent/guardian or the parent/guardian must speak directly the HSE director.

Include First and Last Names *

Statement of Responsibility

I have read the Handbook and I understand that my child must adhere to the regulations while he/she is in attendance on the Holy Souls campus or any scheduled field trips. In the event that I am uncertain of some aspects of the Extended Care policy I will contact the Director for clarification.

I have read the Handbook *

Yes No

Holy Souls Extended Care uses the following methods of descipline:

Verbal Warning

Time Out

Parent Contacted for Conference

Dismissal from the Program

Do you agree with the disciplinary policy above? *

Yes No

If you do not agree with the disciplinary method above list your preferred method.

NO PHYSICAL PUNISHMENT WILL BE USED IN DISCIPLINING ANY CHILDREN

Note: Physical punishment shall not be administered to children under the age of three (3) years. (minimum licensing requirements for child care centers 500.10,p.11)

Preferred Method of Discipline (Type N/A if this does not apply) *

Interviewing Children

In accordance with Minimum Licensing Requirements: DCCECE/Child Care Licensing Unit: 200.3 Child Care Licensing/Investigators/Law Enforcement may possibly interview your child.

I have been informed. *

Yes No

Photo-Video Release

I hereby give permission for my child/children named below to be photographed or videotaped at Holy Souls Extended Care. I realize that the photo or video may be published in the newspaper, a magazine, the school website, social media platforms, or other publications. The video may be used for informational, educational, or marketing purposes regarding the programs at Holy Souls Extended Care. *

Yes No

Permission

The aboved named child/children have permission to watch family friendly PG movies during the summer care program. *

Yes No

Electronic Signature *

Radio Label

Enter Your Email Address: *

Extended Care Registration

Parent/Responsible Party's Contact Information

Enrollment Information

EMERGENCY CONTACT (if parents can not be reached)

Medical Information

Allergy or Medical Condition

Approved Pick-Up List

Statement of Responsibility

Interviewing Children

Photo-Video Release

Permission