NAS Confirmation and Additional child submission

Thank you for submitting your information. It has been received. In order for your registration to be complete, we must receive a physical for each child that was completed on or after August 15, 2017 and you must attend a parent orientation.

If you need to submit information on additional children, please submit the form below for each child.

* Indicates required field

Parent/Guardian Name *

First

Last

Additional Child Information

Name *

First

Last

Date of Birth *

Gender *

Female Male

School for 2019/2020 *

Grade for 2019/2020 *

Name of Teacher *

Allergies (food, bees, latex, nuts, etc). *

Please indicate what you do if your child comes in contact with their allergen (Epipen, hospital, benedryl, etc) *

Does this child have an IEP (Individualized Education Plan) or a 504 Plan? If so, we would like a copy so that we can do our best to follow your child's approved educational accommodations. *

List any medical conditions/needs that your child has. If none, put N/A. *

Are there any medications that your child takes that may need to be administered in an emergency. If so list them and why they would need to be administered. *

My child is able to arrive by 1:00pm *

Yes No

My child can attend all 6 weeks of program *

Yes No

Site Preference* *

*Spots at each site are limited. Your preference choice does not guarantee that you will be assigned to that site.

Pick up Method *

T-Shirt Size *

Please add anything else we should know about your child here: *

Submit

If you need to submit information on additional children, please submit the form below for each child.

Additional Child Information

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