School Attending '09-'10

Father                 Mother:  

Home address:                              Home Address:  
City, St, Zip     City,St, Zip

Home Telephone         Cell          Work:

  Alternate Phone     Alternate Cell

  List all persons authorized to pick up child:  please include Name and Telephone Numbers
Name:   Telephone Number:   

Name:    Telephone Number:  

Please list any medical conditions or allergies that your child may have.
Medical Information: 

Parents Signature: 

I give my child permission to be picked up from his or her school at the end of the school day and attend Lakeview After School Care