Summer Day Camp Emergency Contact Form (Ages 3-5)

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: 01/23/2019

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