Child's Name *
Child's Name
Gender *
Date of Birth *
Date of Birth
Home Address *
Home Address
Home Phone *
Home Phone
Primary Care Giver *
Primary Care Giver
Secondary Care Giver
Secondary Care Giver
Primary Cell Number *
Primary Cell Number
Secondary Cell Number
Secondary Cell Number
The Child May Only Be Released To The Person Signing This Agreement Or To The Following:
The Child May Only Be Released To The Person Signing This Agreement Or To The Following:
Address of Alternate Pick-up Person
Address of Alternate Pick-up Person
Phone Number for Alternate Pick-up Person
Phone Number for Alternate Pick-up Person
Persons To Contact In The Event Of An Emergency When Parents Cannot Be Reached: *
Persons To Contact In The Event Of An Emergency When Parents Cannot Be Reached:
Alternate Emergency Contact *
Alternate Emergency Contact
Does Child Have Allergies (Insects, Medication, Foods, Etc.)?
Is Child on any Regular Medication? *
Medical Authorization:
PARENTAL AGREEMENT WITH BEFORE/AFTER SCHOOL CARE PROGRAM AND MEDICAL AUTHORIZATION 1. Should my child, suffer an injury or illness while in the care of Shoal Creek Adventist School After Care, and administration is unable to contact me immediately, SCAS shall be authorized to secure such medical attention and care for my child as may be necessary including the utilization of 911 services. I shall assume responsibility for payment of services. 2. I agree to keep the facility informed of changes in telephone numbers, etc. where I can be reached. I acknowledge it is my responsibility to keep my child’s records current. 3. No medication will be dispensed to my child. 4. The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medication, etc., that involves my child. 5. Parents are requested to wait until their child is checked in at the door before leaving in the morning. Students must be signed out by a parent/guardian before being dismissed in the evening. 6. I have read the Before/After School Care Policy and hereby agree to comply with the rules and regulations of the Shoal Creek Adventist School Before/After School Care program regarding, but not limited to fees, attendance policy, health, discipline, snacks and other items specified in the Policies and Procedures.
Primary Guardian *
Primary Guardian
Secondary Guardian
Secondary Guardian