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