Application for ASK or SFC



    Name of Child ________________________________________________Birthdate_____________


    Name of Parents or Person placing the child


    Name ____________________________      __________________________________________




    Phone: Work and Cell_____________________________  ________________________

    Place of Employment______________________________


    Other person or persons to notify if the parents cannot be reached






    Child’s Physician _________________________________Phone___________________________


    Does your child have any allergies? If so please explain________________________________




    Does your child have any medical problem we need to know about______________________?


     Emergency Medical Care

    This authorizes After School Kids staff and Summer Fun Club staff to secure EMERGENCY medical care for my/our child when I/we cannot be immediately reached at the time of emergency. I/we will be responsible for the emergency medical charges upon receipt of the statement. __________________is the preferred doctor/clinic/hospital.


    Signature of Parent/Guardian                                                                      Date

    ***If your child is not in Hillsboro school district you will need to get a copy of their physical and shot records for our program.


    Persons picking up your child (please feel free to add more names if needed)






    Trips, Excursions, and Public Park Facilities

    I/we authorize After School for Kids and Summer Fun Club staff to take my/our child on walking trips, special excursions, and to nearby public park facilities. I/we also authorize the child to ride as a passenger on the school bus or school van driven by an authorized person.


    Signature of Parent                                                                        Date