Email Address

Parents Name

Contact Cell/Phone Number

Emergency Contact Name/Telephone Number

Child's Name

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?MorningAfternoonBoth

Morning Pick Up Address

Morning Drop Off

Afternoon Pick up Location/Address:

Afternoon Drop off 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

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