Domus Foundation After-School Program
2013-2014 Application
TO BE FILLED IN BY PARENT OR GUARDIAN
(PLEASE FILL IN ALL BLANKS)
Name of child: ______________________________________________________________________
Age: _________
Date of birth: ___________________
Sex:
__________
Address: __________________________________________________________________
Zip: ___________ Home Phone #: ________________ Alternate Phone #:________________
Parent’s/Guardian’s Name: __________________________ Work Phone #:________________
Does child speak more than one language? ___Yes (language_____________________)
Primary language spoken at home: _____________________________
What school did your son/daughter currently attend 2012-2013 school year?
________________________________________________________________
What grade is your son/daughter in? ____________
Emergency Contact Person 1: ______________________________
Relationship: ____________
Emergency Phone #: _________________________________
Emergency Contact Person 2: ______________________________
Relationship: ____________
Emergency Phone #: _________________________________
I hereby give my consent for my child to participate in all regular programming/field trips planned for the
Domus Foundation After-School Program from September 2013 – June 2014.
I also give Domus Foundation permission to use any photographs/ video taken pertaining to the afterschool program. YES_______
NO________
Printed name of parent or guardian: _________________________________
Signature of parent or guardian: ___________________ Date: ____________
Family Doctor: ___________________ Phone #: _______________ Last Visit: ___________
Does child require special attention in: Eating? _____ Swimming? _____ Allergies? ________
Heart problem? _______ Other? ______________
If so please explain: _________________________________________________________
Do you have any concerns about your child that you would like to discuss with the program
director?
__________________________________________________________________________
__________________________________________________________________________
Any medical problems? _______________________ Specify: _____________________
Does your child take medication? ________ Type: ____________________________
For: ____________________ Dosage: ______________ Time given: __________________
Is child asthmatic?
_____ If yes, does he/she carry an inhaler? ___________________
Is child epileptic? ______ Date of last seizure: _____________________
Is child diabetic? __________
Do you feel that your son/daughter is physically fit to participate in our program without danger to
his/her health?
________ Yes ________ No if no, please explain:
Date of last visit: ___________________
Is the child on medication? _____ Type: _______________________
For: ______________________ Dosage: __________________ Time given: _______
Is the child epileptic? _______Date of last seizure: _________ Is child diabetic? _________
Health History
Is the child’s health, in general, good? _______________________
ALLERGIES OR SENSITIVITY
Is your child subject to?
Rheumatic Fever
Sinus Trouble
Ear Infections
Convulsions
Diabetes
Chicken Pox
Other Drugs
Peanut Butter
_____
_____
_____
_____
_____
_____
_____
_____
Fainting Spells ____
Ivy Poisoning ____
Insect Stings ____
Penicillin
____
Hay fever
____
Asthma
____
Other
____
Other Food
____
Is your child presently or has your child been in the past, under medical care for any illness or
injury? ____ Yes ____ No If yes, please explain:
__________________________________________________________________________
__________________________________________________________________________
Restrictions placed on program activity:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
PARENT OR GUARDIAN’S AUTHORIZATION
This health history is correct as far as I know, and the person herein described has permission to
engage in all activities except as noted by me or by his/her family doctor. If emergency care is
needed by my son/daughter I give my permission to the authorized agents of Domus Foundation
and the Stamford Police Department to seek medical attention fore my child. I authorize
transportation to, and treatment at, a hospital required. I agree to assume all responsibility for all
charges so incurred. I also agree to allow Domus Foundation and the Stamford Police Department
to release any information to the hospital or doctor as may be required.
Insurance Type/Number: _____________________________
Printed name of parent/guardian: ______________________________
Signature of parent/guardian: _________________________________
Child’s Name: _____________________
ADHERENCE TO AFTER-SCHOOL PROGRAM PROCEDURES
I understand that if my child is accepted into the Lion’s Den After-School Program that I will be responsible for adhering to
the rules and procedures, as well as any other Parent Notices communicated by the Director. Such rules and procedures on
behavior, parent drop-off and pick-up, notification of address and contact information changes, and current health
information are critical and I will provide them in a timely manner, as well be available for the Parent Informational Meeting
prior to the start of the after-school program.
PARENT/ GUARDIAN______________________________________
DATE_____________________________
Late Pick-up Bright Line
In those rare occasions you are unable to pick up you child on time please give us a call updating us on the
status of your arrival. If you feel you are running extremely late please consider using someone on your
authorized pick up list to pick your child up. Remember your child will only be released to those individuals
listed on your child’s Authorized Pick-up List. In the event your child is left in our care 30 minutes after our
6:30pm pick-up time a call will be made our local police office and the Department of Children and
Families Hotline.
We will only allow 5 late (after 6:30pm) pick-ups per program. After the 3rd late pick-up a letter will be
sent to home by the director informing the parent/guardian that you will only have 2 late pick-ups for the
program. If a parent/guardian is late five (5) times for pick-up, your child will no longer be able to attend
the program for the remainder of the calendar year.
I, _____________________________, have read the Domus Late Pick-up Bright Line and fully
understand my responsibilities as a parent and the procedures following an infraction of the Late Pickup Bright Line.
Print Name _____________________
Sign Name_____________________
Date__________