"Medical Work Release Authorization Form"
Stafford Township Education Foundation Preschool Registration Form 2009-2010 Child's Name: Gender: M F Address: Birth Date: Town: State: Zip Code: Previous Address: Home Phone #: ( ) Preferred Hospital: Family Doctor: Phone: ( ) Bill To (Please Select One): Mother: OR Father: Valid Email Address to receive Account Statements: 1 Check here if you do not have email access 2 Father's Name: Mother's Name: Home: ( ) Cell: ( ) Home: ( ) Cell: ( ) Address: Address: City/State/Zip: City/State/Zip: Employed By: Employed By: Work Phone: Work Phone: EMERGENCY CONTACT INFORMATION / RELEASE AUTHORIZATION The following individuals are authorized to pick up child and may be contacted in the event of an emergency or school closing **ADDITIONAL EMERGENCY CONTACTS (other than parents): Name Phone 1: ( ) Phone 2: ( ) Relationship to Child Phone 3: ( ) Name Phone 1: ( ) Phone 2: ( ) Relationship to Child Phone 3: ( ) Name Phone 1: ( ) Phone 2: ( ) Relationship to Child Phone 3: ( ) AM/PM Session (1/2 Day) - $16.00 per day Full Day Session - $32.00 per day AM PM Full Day Please Select the days your child will attend: Location: 5 Days - Monday to Friday Oxycocus Monday-Wednesday-Friday Ocean Acres Tuesday-Thursday Annual Registration Fee - $45.00 (Non-Refundable) For Administrative Office Use Only Start Date: Reg. Fee Check # Staff Initials Siblings Name: Age: School Attending: Name: Age: School Attending: Name: Age: School Attending: Did the child attend preschool/nursery school? Yes No If yes, where? For how long? Medical Are there any allergies or medical conditions that we should be aware of? Yes No If yes, please explain: Signature of Legal Parent/Legal Guardian Date ***Please read and initial the following*** I have received and read the Preschool Parent Information Packet, which explains all of the policies regarding the Stafford Township Education Foundation Preschool Program. I have received and read the Department of Family and Youth Services information to parents statement. I have received and read the Stafford Township Education Foundation's expulsion policy located in the Preschool Parent Information Packet.