Contact Cell/Phone Number

Parents Name

Emergency Contact Name/Telephone Number

Email Address

Child's Name

Child's Age

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

Does your child need morning ,afternoon pick up, or both? Does your child need morning ,afternoon pick up, or both?MorningAfternoonBothNone

Morning Pick Up Address

Afternoon Pick up Location/Address:

I affirm that I have not been exposed to anyone that has been diagnosed with COVID-19 within the past 14 days inside or outside of the country I reside in. I affirm that I have not been exposed to anyone that has been diagnosed with COVID-19 within the past 14 days inside or outside of the country I reside in. Yes NO

Message