GLEN RIDGE PUBLIC SCHOOLS
CHILD
CARE PROGRAM
Registration Form- 20___ – 20___ School Year
(Please print out
this form and mail it to:
Parent’s/ Guardian’s
Names:_____________________________________________________________
Address:___________________________________________
E-mail: (VERY IMPORTANT!).
Phone:
__________________________
Child’s
Name:_____________________School:______________Teacher:___________Gr.____
Child’s
Name:_____________________School:______________Teacher:____________Gr.___
Child’s
Name:_____________________School:______________Teacher:____________Gr.___
Before Care Program Pre-K
only (pm class)- (
Please circle only the days to be used (i.e.,
M-F, T & Th, or “as needed”)
1st
Child: M T W Th F or As Needed
2nd
Child: M T W Th F
or As Needed
3rd
Child: M T W Th F
or As
Needed
Before Care Program (Pre-K-6)
LINDEN-7:30AM-
Please circle only the days to be used (i.e.,
M-F, T & Th, or “as needed”)
1st
Child: M T W Th F or As Needed
2nd
Child: M T W Th F
or As Needed
3rd
Child: M T W Th F
or As Needed
I understand that my
child(ren) must be accompanied into Before Care and signed in by myself or
another adult.
After Care Program
Please circle only the days to be used
(i.e., M- F, T &Th, or “As Needed”)
Please circle the days your child(ren) will
be attending as well as the time.
1st Child: M
T W
Th F or As Needed
2nd Child: M
T W
Th F
or As Needed
3rd Child: M
T W
Th F
or As Needed
Please call the Program Director at 973.429.1269 to report your child’s
absence from After Care on a scheduled day or to have your child come “as
needed.”
Signature________________________________________
Date:_________________________
EMERGENCY INFORMATION
Mother’s Name:_____________________________Cell#_________________________________
Father’s
Name:_____________________________________Cell#_________________________
Home
Address:_____________________________
Home Phone_______________________
Child’s
Name:___________________________________________
D.O.B._______________________
Child’s
Name:___________________________________________
D.O.B._______________________
Child’s
Name:___________________________________________
D.O.B._______________________
EMPLOYMENT INFORMATION:
Mother’s
Employer:____________________________Ph. #_______________________
City/State of
Employer ________________________________________________________________
Father’s
Employer:____________________________________Ph.________________________
City/State of
Employer ______________________________________________________________
LOCAL EMERGENCY PERSON (do not list
parents)
Name:____________________________
Phone
#:_________________Cellular #___________________
Address:_____________________________________Relationship_________________
DOCTORS INFORMATION:
Name:____________________________________
Phone
#__________________________________
Address:_________________________________
Hospital___________________________________
Parent
Signature:__________________________________Date:____________________
PERMISSION CONSENT FORM
I (We) wish to
enroll ____________________________ in the
I hereby grant
permission for my child(ren), as listed on the front page, to use all play
equipment and participate in all activities, trips, and events of the
I hereby give
permission for my child(ren) to leave the school premises under the supervision
of the program’s staff for walks, outings to the park, and trips on scheduled
days.
In the event I (we)
cannot be reached in an emergency, I give permission to the Glen Ridge Public
Schools Child Care Program staff to authorize life-saving emergency medical
care by a qualified physician and/or hospital personnel for my child(ren).
Listed below are the names of adults
authorized to pick up my child(ren) without any prior notification from
parents/ guardians:
Name Relationship
Phone Number
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Check here if there
are additional names on back of paper:______.
I have read the Glen
Ridge Child Care Program Family Handbook and am fully aware of its contents.
To the best of my
knowledge, my child(ren) has (have) no conditions which restricts his/her/their
full participation in the program. If, in the future any restrictions are
necessary, I will inform the program in writing.
Check here if your
child(ren) has (have) any restrictions: ________. If checked, please put
explanation on Emergency Medical information sheet.
I grant my
permission for my child(ren) to participate in the Glen Ridge Child Care
Program.
I agree to abide by
the policies and to pay all fees incurred while using the program.
__________________________________
Parent/Guardian
Signature Date
Child’s Name: Grade: School:
In the event of an emergency
school closing, the above children should: (Please check one)
attend
the After School Child Care Program upon dismissal only if it is his or her scheduled day.
attend
the After School Child Care Program upon dismissal regardless of whether or not
it is his or her regularly scheduled day. I will pay any extra fees to the
Child Care Program, if it is not their regularly scheduled day.
_____________
be dismissed directly from school to an
authorized person or location.
In the event of an emergency school closing, After Care will close
early as well. Please make arrangements so that your child(ren) can be picked
up from After Care as soon as possible following their early dismissal from
school.
Signature
C O N FI D E N T I A L
Emergency Medical
Information
To insure your child(ren)’s safety please
list below any medications, allergies (bees, nuts, etc.) or conditions (asthma,
etc.) that your child(ren) may have.
______________________
____________________
Signature Date