Saints Inc Registration Form

Child's Name*
First Last
Child's Birthdate*
MM slash DD slash YYYY
Child's Current Grade*
Child's Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent 1 Name*
First Last
Parent 1 Phone*
Parent 1 Email*
Parent 2 Name*
First Last
Parent 2 Phone*
Parent 2 Email*
Emergency Contact Name*
First Last
Must be different from Mother or Father.
Emergency Contact Phone*
Before School Care: Select the days your child will most likely attend.
- Select All
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Saints Inc. is available on school days beginning at 7:00 am - 7:45 am.
After School Care: Select the days your child will most likely attend.
- Select All
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Saints Inc. is available on school days beginning after school from 2:35 PM - 5:30 pm.
Does your child have any health issues such as allergies (seasonal, food, etc.), asthma, medication requirements, or activity restrictions?*
Examples may include: Diabetes Mental Health ADD/ADHD (diagnosed) Food Intolerances/Allergies Seizures/Neurological Asthma/Respiratory Heart/Cardiovascular Please note if your child has a life-threatening allergy that may require carrying his/her own Epi-Pen (physician's orders required).
Physician/Clinic and Phone Number*
Please provide a list of all authorized adults to pick up your child. Please include their phone number. (Example: John Smith, 123-456-7890)*
Please provide a list of all non-authorized adults to pick up your child. (If not applicable, please put NA)*
Optional: List any other information you would like our Saints Inc. directors to be aware of about your child.
Consent*
I agree to the consent policy.
I understand the information on this form is given voluntarily. This information is collected to provide your student’s health and safety while at Saints, Inc. Your signature gives permission to share health concerns with appropriate staff for your student’s safety. Hearing and vision screenings are provided to students according to state guidelines. Your signature also authorizes the school to contact the doctor/clinic listed above and/or to provide emergency vehicle transportation to the hospital in the event that you cannot be reached in an immediate emergency. Your signature also gives us permission to use your child's image on social media and in print marketing. The parent(s) /guardian(s) are responsible for all expenses.
Parent Signature / Date*

Example: John Smith 6/19/2019

Saints Inc. Registration

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