1 . CHILD'S INFORMATION

LAST NAME           FIRST NAME  

MIDDLE NAME         ADDRESS    

DATE OF BIRTH        AGE GENDER  MALE FEMALE

 

2 . PARENT INFORMATION

   MOTHER  FATHER
NAME  
OCCUPATION  
OFFICE ADDRESS  
OFFICE TELEPHONE  
HOME ADDRESS  
HOME PHONE
     

3 . RESPONSIBLE FRIENDS/RELATIVE TO CALL IF PARENTS CANNOT BE REACHED.

   
NAME 1
TELEPHONE
NAME 2
TELEPHONE
NAME 3
TELEPHONE
   

4 . NAMES OF ALL PERSONS AUTHORIZED TO REMOVE CHILD FROM SCHOOL

   
NAME 1
TELEPHONE
NAME 2
TELEPHONE
NAME 3
TELEPHONE
   

5 . THE FOLLOWING LICENSED PHYSICIANS IS AUTHORIZED TO GIVE EMERGENCY CARE TO MY CHILD

PHYSICIAN'S NAME ADDRESS NATIONALITY/STATE  PHONE
       

IF NOT AVAILABLE ANOTHER LICENSED PHYSICIAN MAY TREAT MY CHILD :  YES  NO

NAME OF PARENT'S INSURANCE COMPANY

 COMPANY NAME ADDRESS CONTRACT NO
     

6 . FINANCIAL ARRANGEMENT

7 . AUTHORIZATION IS HEREBY GIVEN TO THE ABOVE NAMED SCHOOL TO PROVIDE TRANSPORTATION FOR MY CHILD : YES  NO

 

SIGNATURE OF EXECUTIVE DIRECTOR IYAHEN INT. ACADEMY  DATE SIGNATURE OF ADMITTING CHILD DATE