St. Hilary Extended Care Enrollment

Information  2005 - 2006

____________________   ____________________     _______________

Last name of student                     First name                                 DOB

____________________________________________________        ___________________

Address                                                                                                      home phone

Days attending regularly:

M                         T                          W                         TH                                 F

Drop in only:

Approximate time to be picked up__________________

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__________________            _______________          _____________

Father's Name                                 Business Address                    Business Telephone

__________________            _______________          _____________

Mother's Name                                Business Address                    Business Telephone

Other Number's (cell phone, pages, etc.):    _____________________________________

E-mail: __________________________________________________________________                                                                                                                                   

Siblings at school/grade:    ___________________________________________________

In the event of apparent serious illness or accident, when I cannot be reached, I wish one of the following to be notified. They are authorized to act in my absence, and  will be informed that their names have been used on this card. Please do not list mother or father in spaces below; it must be someone NEARBY who can be reached quickly.

__________________            _______________          _____________

Name                                                        Address                                    Telephone

__________________            _______________          _____________

Name                                                        Address                                    Telephone

__________________            ______________          _____________

Name                                                        Address                                    Telephone

          In the event of apparent serious illness or accident, when I cannot be reached, I wish one of the following to be notified.  They are authorized to act in my absence, and will be informed that their names have been used on this card.  Please do not list mother or father in spaces below; it must be someone NEARBY who can be reached quickly.   

________________  __________________  ___________________

Name                      Address                                 Telephone Number

________________  __________________  ___________________

Name                      Address                                 Telephone Number

________________  __________________  ___________________

Name                      Address                                 Telephone Number

In case of minor injury, I authorize first aid be administered by a person qualified to render such service.  In case of an accident may we contact your Family Doctor or Dentist?

_________Yes        ________No

_____________   ______________    ______________

Family Doctor              Address                                  Telephone Number

________________    __________________    ___________________

Family Dentist            Address                         Telephone Number

________________    __________________    ___________________

Hospital                     Address                          Telephone Number

_______________    ___________________    ___________________

Insurance Company   Address                           Telephone Number

Please describe any physical, medical, or emotional conditions, including allergies to food or medication that should be considered for your child in any emergency situtation.

Authorized people to whom my child can be released:

_____________________________________________________________

_____________________________________________________________