The Park District of La Grange Before and After School Recreational Experience
2015-16
Registration / Emergency Form
1ST – 6TH Grade Only
CHILD’S HOME SCHOOL_________________
Student’s Legal Name________________________________________
Address___________________________________________________
Please indicate choice:
Home Phone _______________________Cell Phone_______________
1). Before School Care
(____)
(7:00-8:15 a.m. M-F)
( ) Male ( ) Female *Birth date _________ *Age_______Grade_______
2). After School Care
(3:15-6:00 p.m. M-F)
(2:30-6:00 p.m. W)
PLEASE WRITE LEGIBLY
In order to provide the best care for your child, please answer the following:
(____)
3). Before and After School (____)
Does your child have any health or dietary problems that may affect
his/her activities or diet (e.g. epilepsy, rheumatic fever, diabetes, allergies,
heart trouble etc.)?
Yes___ No___ If yes, please attach a separate explanation with details.
Registration for 1st- 6th Grade
Fee $30.00 per child
Does your child have any special needs or is your child receiving any special
services from school or other agencies?
Yes___ No___ If yes, please attach a separate explanation with details.
Make checks payable to:
Park District of La Grange
No Cash Accepted
NO REFUNDS
Father’s Name______________________________ _______ Employer______________________________
Email_____________________________________________ Work Phone __(____)____________________
Pre-
Mother’s Name_____________________________ ________ Employer _____________________________
Email______________________________________ ____ Work Phone __(____)_______________________
Guardian __________________________________ ________ Employer _____________________________
Email__________________________________ ________ Work Phone _______________________________
Child resides with: both parents____
mother____
father____
other____________
In addition to those listed above, in case of an emergency, we have your permission to contact and or release your child(ren) to:
Name _______________________________Phone ____________________ Relationship__________________
Name _______________________________Phone ____________________ Relationship__________________
Name _______________________________Phone ____________________ Relationship__________________
Name _______________________________Phone ____________________ Relationship__________________
Doctor’s Name / phone _______________________________________Hospital Preference_________________
*IF ANY INFO CHANGES,
PLEASE NOTIFY THE BASE
SUPERVISOR.
_____________________________
Signature of Parent/ Guardian
_______________
Date
Note- Students may begin BASE after their information is reviewed and verified
Parents will receive an email confirmation
5/22/15