ColumbiaAdventistAcademy.com: Aftercare Registration Form

Aftercare Registration Form

School Year

Student Name
Address
Home Phone #
Mother's Name
Mother's Work #	Beeper/Mobile
Father's Name
Father's Work #	Beeper/Mobile
Emergency Contact Person
Emergency Contact #
List names of those permitted to pick up your child:



List any allergies or health concerns:



Doctor's Name	Office Number
Preferred Local Hospital
We, the undersigned parents or legal guardian of the above student, do hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital services that may be rendered. It is understood that reasonable effort will be made to contact the parent/guardian and the doctor listed above before any other physician is called by the school. It is understood that this consent is given in advance of any specific diagnosis or treatment which might be required.






Parent or Legal Guardian		Date
Would you be interested in substituting for one of the Aftercare personnel when the need arises? Yes No