Midway After-School Child Care Program

PANTHER KIDS ENROLLMENT 2015-2016

Midway After-School Child Care Program

Campus______

Please complete the information below for each child in your family you wish to enroll in Panther Kids. Forms and $25 enrollment fee (one per family, non-refundable) can be dropped off at your child’s school or the Midway Administration Building or they can be mailed to MISD, 13885 Woodway Dr., Woodway, TX 76712.

1. Child’s Last Name ______First ______Middle Initial _____

Age on 9/1/15:____ Grade 2015-16:______Date of Birth: ______Qualified Free/Reduced Lunch? ______

This child is in special education is served under Section 504 has allergies or special medical needs. *

2. Child’s Last Name ______First ______Middle Initial _____

Age on 9/1/15:____ Grade 2015-16:______Date of Birth: ______Qualified Free/Reduced Lunch? ______

This child is in special education is served under Section 504 has allergies or special medical needs. *

3. Child’s Last Name ______First ______Middle Initial _____

Age on 9/1/15:____ Grade 2015-16:______Date of Birth: ______Qualified Free/Reduced Lunch? ______

This child is in special education is served under Section 504 has allergies or special medical needs. *

*For children with disabilities, allergies, or special needs, please complete Special Needs form found on our website.

Parent Information

Family Residence Address ______

Street Address CityState Zip

Father’s Name ______Place of Work ______

E-mail Address:______

Work Phone ______Home Phone ______Cell Phone ______

Mother’s Name ______Place of Work ______

E-mail Address:______

Work Phone ______Home Phone ______Cell Phone ______

Name of Person(s) Financially responsible for Panther Kids tuition______

Emergency Contact Name ______

Work Phone ______Home Phone ______Cell Phone ______

In the event of a medical emergency and I cannot be reached, I authorize the proper Midway officials to administer appropriate

first-aid and, if necessary, call 911 for emergency medical care and possible transport by ambulance to a hospital. I assume all responsibility for medical expenses incurred.

______

Signature of Parent/Guardian—Admission to Panther Kidswill not be considered without a signature. Date

-OVER-

Panther Kids Pick Up Information

Please list all persons who are authorized to pick up your child from Panther Kids,

After-School Program. We are assuming parents listed on enrollment form can pick up.

Name RelationshipContact Phone #’s

1. ______Work______

Home______

Cell______

2. ______Work______

Home______

Cell______

3. ______Work______

Home______

Cell______

4. ______Work______

Home______

Cell______

5. ______Work______

Home______

Cell______

6. ______Work______

Home______

Cell______

7. ______Work______

Home______

Cell______

8. ______Work______

Home______

Cell______

3-30-15 DR