Falcon’s Nesting Place

REGISTRATION FORM (2008-2009) 

Please print out the following, complete, and return to the Folsom School.

Starting Date_______________  

First Child ______________________________Age: ______ Grade: _____

Second Child____________________________ Age: ______ Grade: _____

Third Child _____________________________ Age: ______ Grade: _____

SESSIONS:       AM                      DAYS:     M     T     W     TH     F

                            PM                      DAYS:     M     T     W     TH     F

Parent\Guardian with whom child \children resides:

Name: _______________________________ Home Phone:__________________ Cell Phone: ___________________________

Mailing Address:

Street: _________________________________________________

Town: _____________________________ Zip Code: ____________

Employer: (mom) _____________________Work Phone: ______________ Cell Phone: ___________________________

Employer: (dad) ______________________Work Phone: ______________ Cell Phone: ___________________________

Person(s) Authorized (must show ID) to pick up child\children:

Name:________________________________Phone:__________________ Cell Phone: ___________________________

Name:________________________________Phone:__________________ Cell Phone: ___________________________

Name:________________________________Phone: __________________ Cell Phone: ___________________________  

Personal Property Release:  I understand that the FFNP is not responsible for any property belonging to my child\children, which is left or lost at Program sites. 

Authorized Signature_______________________Date:__________

Photographic Permission:  I grant permission and authorization to have my child appear in any media coverage approved by the FFNP.  I understand that the Coordinator in conjunction with the Board of the Program, has the authority to determine appropriate requests.

Authorized Signature_______________________Date_______

Emergency Numbers: Please give the name, address and phone number of two people that may be notified in case of an emergency of illness, when parents or guardians are not available.  These people should live in the district of Folsom. Please provide a telephone number where these people can be contacted during program hours.

1.   Name:________________________________________

      Address:______________________________Phone:_______________ Cell Phone: ___________________________

2.   Name:________________________________________

      Address: _____________________________Phone: _______________ Cell Phone: ___________________________

Emergency Medical Release: If emergency medical care is necessary and I cannot be contacted, I authorize the FFNP Staff to act in my behalf in granting permission for my child to receive emergency treatment.

Authorized Signature: ______________________________ Date: _______

Medical Problems\Concerns:  Please note below any medical problems or other information that should be brought to the attention of the FFNP staff.

__________________________________________________________________________________

__________________________________________________________________________________

Medical Insurance Information:

Company: ____________________________Policy No._______________

A registration fee of  $50.00 must accompany this form.  Please make check or money order payable to: Falcon's Nesting Place (No Cash accepted).

$10.00 non-refundable application fee - $40.00 applied to June hours