CHILD'S NAME (FIRST, MIDDLE, LAST)         BIRTH DATE                                                   STREET             GRADE                                                   CITY     ZIP   PHONE   GENDER RACE   STUDENT               M     INFORMATION               F       REGISTRATION DATE STARTING DATE SCHOOL OF ATTENDANCE                                                       PROGRAM   DAYCARE     PRE-SCHOOL     SACC     DAYS                      ATTENDING M           T  W TH          F  M           T  W TH          F  M           T  W TH          F    OUR CLASS ROSTERS INCLUDE: CHILD'S NAME, PARENT/GUARDIAN NAME, ADDRESS & PHONE NUMBER       I WOULD LIKE TO BE INCLUDED IN THE CLASS ROSTER   YES   NO       NAME (FIRST & LAST)         RELATIONSHIP TO STUDENT                                                     HOME ADDRESS         EMPLOYER       PARENT                     AND/OR                     GUARDIAN HOME PHONE           WORK PHONE                           1 (                           )         (                           )         CELL PHONE           PAGER                               (                           )         (                           )       NAME (FIRST & LAST)           RELATIONSHIP TO STUDENT                                                     HOME ADDRESS         EMPLOYER       PARENT                     AND/OR                     GUARDIAN HOME PHONE           WORK PHONE                           2 (                           )           (                           )         CELL PHONE           PAGER                               (                           )         (                           )       NAME       RELATIONSHIP  DAYTIME PHONE       AUTHORIZED                     PICK UP &             (                           )       EMERGENCY NAME       RELATIONSHIP  DAYTIME PHONE     CONTACT                                   (                           )       NON-PARENT NAME       RELATIONSHIP  DAYTIME PHONE     ONLY                                   (                           )       IN CASE OF EMERGENCY:    I HERBY GIVE MY CONSENT FOR FIRST AID, MEDICATION, TREATMENT AND TRANSPORTATION TO AN EMERGENCY         CARE FACILITY.   YES   NO        ALLERGIES/DIETARY RESTRICTIONS         MEDICATION (ANY PRESCRIPTION MEDICATION TAKEN)         FIRST                     AID                     INFORMATION FAMILY DOCTOR       PHONE                                           (                           )           DENTIST         PHONE                                            (                           )                                                                   PARENT/GUARDIAN SIGNATURE & DATE       OFFICE PERSONNEL SIGNATURE & DATE