After School Program for Kindergarteners

After School Program for Kindergarteners

2013/14 School Year

Contact& Health Form

Child’s name: / Date of Birth: / Age:
Child’s Primary Address: (Street, Apt. # and/or PO Box, City, State, Zip)
Parent/Guardian 1 Name: / Parent/Guardian 2 Name:
Parent/Guardian 1 Home Address (if different): / Parent/Guardian 2 Home Address (if different):
Parent/Guardian 1 Business Phone: / Parent/Guardian 2 Business Phone:
Parent/Guardian 1 Home Phone: / Parent/Guardian 2 Home Phone:
Parent/Guardian 1 Cell Phone: / Parent/Guardian 2 Cell Phone:
Parent/Guardian 1 Email: / Parent/Guardian 2 Email:
Emergency Contacts (other than Parent/Guardian):
You must list at least one emergency contact. Please include phone numbers.
1. Name: / Relationship to Child: / Phone Numbers:
2. Name: / Relationship to Child: / Phone Numbers:
3. Name: / Relationship to Child: / Phone Numbers:

Are there any cognitive, physical, or emotional needs that your child may have at this time?

Please identify:

And if so, are there any techniques you know of that will aid us in supporting your child’s progress?

Does your child have any allergies to the outdoors, medicines, food, clothing, animals, etc.?

Please list:

Is your child currently taking any medications that we should know about?
Please list:

Can Island Kids staff be allowed to give your child any medication if s/he feels sick? If yes, what will you allow (i.e. Tylenol, Pepto-Bismol, Aspirin, etc.)?

Please Note: Children with severe allergies should be sent to camp with the necessary medications (Epi-pen, Benadryl, etc.) stored in a zip-lock bag, clearly marked with the student’s name, along with instructions for use, which should be handed to an Island Kids staff member on the first day of the program. Please note that failure to inform Island Kids staff about a severe allergy can result in expulsion from the program.

Medical Information

Is your child covered under your families insurance? Yes _____No______

Doctors Name:Phone:

Insurance Co.:Policy #:

Parental Permission

Island Kids, Inc, has permission for my child to participate in programs that are planned and supervised by Island Kids. Island Kids, Inc. has permission to treat my child for routine, minor injuries such as scrapes and bruises. In the event that my family physician cannot be contacted in an emergency, I hereby grant Island Kids, Inc. Staff permission to bring my child to be treated at a hospital emergency room.

Signature: Date:

Print Name:Relationship to Child: