Jump 2 Learning Emergency Contact Form
Child's Last Name
Child's First Name
Age
Home Phone Number
-
-
Birth Date(mm/dd/yyyy)
Male/Female
Male
Female
Home Address
City
Zip/State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
  N/A
  N/A
Father's Last Name
Mother's Last Name
Father's First Name
Mother's First Name
Address(if different from child's address)
Address(if different from child's address)
City
City
Zip
Zip
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Phone Number
-
-
Phone Number
-
-
Additional Phone Number
-
-
Additional Phone Number
-
-
Employer
Employer
Emergency Contact
(MUST BE SOMEONE OTHER THAN MOM AND DAD AND LIVE AT A DIFFERENT ADDRESS THAN THE CHILD)
Last Name
Address
First Name
City
Phone Number
-
-
Zip
Additional Phone Number
-
-
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Relationship
Additional Persons Authorized to Pick Up the Child
In addition to my child's legal guardians and emergency contact listed above, I hereby authorize Powersports to allow my child to leave
ONLY
with the following persons. Name and telephone number are needed for each. Children will only be released to a parent or person designated by the parent/guardian after verification of ID.
Last Name
First Name
Phone Number
-
-
Optional: I hereby give my consent for my child to be released to the following siblings who are under 18 years.
Name of Sibling(s)
Medical Information
List any medical problems that your child may have, such as allergies, exiting illnesses, previous serious illness, injuries, any medication prescribed for long-term continuous use, and any other information which caregivers should be aware of:
Authorization for Emergency Medical Attention Agreement
In the event that I cannot make arrangements for emergency medical care, I authorize the person in charge to take my child to:
St. Joseph Regional Health Center, 2801 Franciscan Dr, Bryan, TX 77802, 979-776-3777
College Station Medical Center, 1604 Rock Prairie Rd, College Station, TX 77845, 979-764-5100
The Physicians Hospital, 3131 University Dr East, Bryan, TX 77802, 979-731-3100
Scott & White Healthcare, 1600 University Drive E, College Station, TX 77840, 979-691-3300
Scott & White Memorial Hospital, 700 Scott & White Dr, College Station, TX 77845, 979-691-3400
Immunization Agreement
I understand that I must have a current shot record and a current health release statement on file before my child can attend preschool.
Discipline Agreement
I have read and understand the Student Discipline Guidelines and agree to follow them in accordance to the parent handbook.
Acknowledgment of Handbook
By signing my name, I agree that I have read in full the Powersports Jump 2 Learning policies and procedures and will abide by them.
Health Statement Agreement
My child is going to be seen by a childcare physician in the next 12 months.
Also, my signature verifies receipt of the Discipline and Guidance Policies and permits Powersports to obtain emergency medical treatment if needed. All agreements may be found in the Jump 2 Learning/Friday Play Day Handbook.
Signature:
Clear
Date:
12/13/2024
By signing here I verify all information in this form is correct and agree to all Powersports policies and procedures.
Once your form is submitted, you must call Powersports to complete your registration