Christ the King Catholic School

After School Care Registration Form

Christ the King After School Care Registration Form

501-225-6774 ext 253           501-553-1732         Kenzie Cundall, Director

Child(ren)’s Name(s)                                                                           Date of Birth     Grade

______________________________________________________  ___________  ________

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______________________________________________________  ___________  ________

 

 

      FULL TIME:            My Child(ren) will attend CTK ASC on a full time (monthly rate) basis

     DROP IN w/ REG:     My Child(ren) will attend CTK ASC on a drop-in (daily rate) basis with the registration fee paid.

     DROP IN /no reg:     My Child(ren) will attend CTK ASC on a drop-in (daily rate) basis with no registration fee.

 

Address                                                                                                                                                                       

Home Phone:                                                         Preferred Email                                                                                                                                              

 

Father’sName:

 

Mother’s Name:

 

Cell #:

 

Cell #:

 

Work Phone:

 

Work Phone:

 

Workplace:

 

Workplace:

 

Work Hours:

 

Work Hours:

 

 

 

 

 

 

Emergency Contacts:  (2 References are REQUIRED by the Department of Human Services)

Name #1           Relationship      Address            _ Phone            _ Name #2        Relationship      Address

May the emergency contacts above pick up your child? #1           yes         no                   #2         yes         no

 

Who else may pick up your child?                                                                     Relationship                                                                                                                                                              

                                                                                                                                                              Relationship                                                                                                                                                              

                                                                                                                                                              Relationship                                                                                                                                                              

 

Does your child have any medical problems, conditions, or allergies? If so, explain:

                                                                                                                                                                            

                                                                                                                                                                           

 This information is required for the Arkansas Department of Human Services.

 Child's Physician                                                 Address                                                      Phone 

_____________________________________  _________________________________  _______________ 

 

Parent’s Signature & Date

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