Parent/Guardian Information. Program Hours □9:00 a.m. – 5:00 p.m. □6:30 a.m. - 9:00 a.m. □5:00 p.m. – 6:30 p.m. Last Name First Name: _ Street Address: City, State, Zip code: Home Telephone Number: Work Telephone Number: Cellular Number: Relationship: E-Mail: Last Name First Name: Street Address: City, State, Zip code: Home Telephone Number: Work Telephone Number: Cellular Number: Relationship: E-Mail: Medical Information Allergies: Pediatrician: Telephone: Pediatrician’s Address: Family Information Language(s) spoken in the home: List other children in the family: Name: Age: Sex: Name: Age: Sex: Name: Age: Sex: Emergency Contacts: (Other than parents) Name: _ Phone: Name: Phone: Please attach custody documents if applicable: Please attach child’s photo here: I agree to the enrollment of my child , at Eco-Tots Early Learning Center in the following program: Summer “Eco” Camp Before/After Care
Parent/Guardian Information. I certify that the information that I have provided regarding any health conditions listed for my child is true and accurate. I hereby state that I have read and fully understand my choices for the administration of medication at school. In the case that my child’s medication is distributed at school, I agree to release the District and/or all District personnel from liability for any and all injuries that may result from my child taking or neglecting to take medicine prescribed. I have read and understand that: In the event of a critical emergency, emergency medical services will be utilized and the parent/guardian will be contacted as soon as possible. The parent/guardian is responsible for the cost of any medical treatment that their child may require. A student’s health information is kept confidential and will only be accessible to school staff who need to be aware of this information. Parent/Guardian Signature Relationship Phone Number Date For more specific information, please see Policy 2830, Regulation 2410, and Regulation 2870 posted on the Wentzville School District Website. N-1 rev 1-11-2021 Page 2 of 2
Parent/Guardian Information. ● All parents/guardians are invited to attend an informational meeting about one-to-one learning. For those who cannot attend, a video presentation will be available on the Resurrection website.
Parent/Guardian Information. Mother _______________________________________ First Last Address (if different from student’s):______________________________________________ Mother’s Home #: Mother’s Cell #: Mother’s Work #: Occupation: ___ Mother’s Employer and address__________________________________________________ ______________________________________________________________________________ Father_______________ _______ ________________________ First Last Address (if different from student’s):______________________________________________ Father’s Home #: ____ Father’s Cell #: ___ Father’s Work #: ________ Occupation: _________ Father’s Employer and address ______________________________________________________________________________ Special instructions for reaching parents/guardians:_____________________ In case of an Emergency We will first use the information listed above and if we get no response we will contact: Emergency Contact 1 Name: Relation: Home Phone Cell Phone Address Emergency Contact 2 Name: Relation: Home Phone Cell Phone Address People allowed to pick up your child: (Will be required to show ID)
Parent/Guardian Information. Mother First Last Address (if different from student’s): Mother’s Home #: Mother’s Cell #: Mother’s Work #: Occupation: Mother’s Employer and address Father First Last Address (if different from student’s): Father’s Home #: Father’s Cell #: Father’s Work #: Occupation: Father’s Employer and address Special instructions for reaching parents/guardians: In case of an Emergency We will first use the information listed above and if we get no response we will contact: Emergency Contact 1 Name: Relation: Home Phone Cell Phone Address Emergency Contact 2 Name: Relation: Home Phone Cell Phone Address People allowed to pick up your child: (Will be required to show ID)
Parent/Guardian Information. If you are completing this for yourself and you are 18 years of age or older type self in first box and complete section. Parent/Guardian Parent/Guardian Email Address Parent/Guardian Phone Number EMERGENCY CONTACT INFORMATION First Name Last Name Phone Number Relationship to Participant (Please turn over to complete)
