Puddle Jumpers Boarding Pass 2007-2008

							                       Puddle Jumpers Boarding Pass 2009-2010
              ***Please fill out one form for each child in PreSchool-Kindergarten***
Student:
Name: ____________________________________________________________
Address:__________________________________________City:_____________
Phone Number : _______________________________

Age: _________ (must be 3 years old by 9-1-09) Date of Birth:_____________________

Grade: Pre School (age 3) Pre Kindergarten (age 4)            Kindergarten (age 5)

Mother: ______________________________________________________
Address: ____________________________________________City:____________
Phone Number: _______________________Cell Phone Number:_______________
Email: ________________________________________________________

Father: ______________________________________________________
Address: ____________________________________________City:____________
Phone Number: _______________________Cell Phone Number:_______________
Email: ________________________________________________________

Name and age of siblings attending:
___________________________________________________________________

Emergency Contact Person:
_____________________________________Phone#:_______________________

Important medical information (asthma, allergies, diabetes, etc)
___________________________________________________________________

________________________________________________________________
 Emergency Release Information: If I cannot be reached immediately, I authorize Mt. Olive
staff to drive to the physician, dentist or hospital. Ambulance may be called if necessary.

Parent Signature: _______________________________Date: ________________

      I would like to help with Puddle Jumpers.