Father's Name:
Address:
City:		Zip Code:
Cell Phone:
Home Phone:
Work Phone:

Mother's Name:
Address:
City:		Zip Code:
Cell Phone:
Home Phone:
Work Phone:

Physician's Name:
Phone number (including area code):
Preferred Hospital:
Insurance:

Child's Name:
Grade:
Medical Conditions/Allergies:

Child's Name:
Grade:
Medical Conditions/Allergies:

Child's Name:
Grade:
Medical Conditions/Allergies:

Child's Name:
Grade:
Medical Conditions/Allergies:

I am requesting Before Care
I am requesting After Care
I am requesting Before and After Care
I authorize the following people to pick up my child/ren if I am unavailable. *Note: authorized people should be prepared to show identification*
Name and relationship:
Name and relationship:
Name and relationship:
I authorize supervisory personnel at St. Vincent de Paul School's Care Program to provide necessary emergency care and services in the treatment of sudden illness or injury to my child/ren if I cannot be contacted by phone.
I agree to the above waiver.
Parent/Guardian Name: Date: