After School Program Student #1 Name*Grade*Student #2 NameGradeStudent #3 NameGradeParent/Guardian Full Name*Mother's Email*Parent/Guardian Phone*Parent/Guardian 2: NameParent/Guardian 2: EmailParent/Guardian 2: PhoneEMERGENCY CONTACT #1: Name, Relation to Student, and Phone Numbers (Cell/Work/Home)EMERGENCY CONTACT #2: Name, Relation to Student, and Phone Numbers (Cell/Work/Home)EMERGENCY CONTACT #3: Name, Relation to Student, and Phone Numbers (Cell/Work/Home)Physician's NamePhysician's PhoneChild/Children lives with (check all that apply) Mother and Father/Guardians Mother/Guardian Father/Guardian Stepmother Stepfather OtherOther RelationshipWho has legal custody?*Name of person financially responsible?*List of persons other than parent who may pick up student. Please include phone numbers.*Please list any special instructions for your child including Allergies, Diet, Medical, etc.*By submitting this form, I/we, the parent(s)/legal guardian(s) of the students named above, have read, understand, and agree to abide by the Policies and Procedures and the Registration Agreement of The Westfield School After School Program. I also will assume liability for accidents and injuries incurred during the After School Program. In the event of emergency, I authorize the persons in charge to seek immediate medical attention for my child. Submit
